This study is a systematic review focusing on adolescent dietary diversity and micronutrient deficiencies in Malawi and Ghana. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure transparency and reproducibility. The objective was to comprehensively identify, evaluate, and synthesize empirical evidence related to nutritional challenges, food security, and their implications for adolescent health in the two countries. Figure 1 illustrates the identification, screening, eligibility assessment, and inclusion of studies on adolescent dietary diversity and micronutrient deficiencies in Malawi and Ghana.

A systematic literature search was conducted across multiple electronic databases, including PubMed, and Google Scholar.

The search strategy combined free-text keywords and Boolean operators, using terms such as: •

“Adolescent nutrition” AND “Malawi”

The search was limited to articles published in English between 2014 and 2025. Reference lists of eligible studies were screened manually to identify additional relevant sources.

This study is a systematic review that evaluates evidence on adolescent dietary diversity and micronutrient deficiencies in Malawi and Ghana, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines.

The primary aim was to synthesize findings related to nutritional challenges, food insecurity, and their implications for adolescent health. A PRISMA flow diagram ( Figure 1) outlines the study selection process.

We systematically searched four electronic databases: PubMed and Google Scholar for studies published between 2014 and 2025. The search strategy used Boolean operators and combinations of keywords such as: •

“Adolescent nutrition” AND “Malawi”

We also reviewed grey literature from WHO, UNICEF, FAO, and national nutrition policy documents. Manual reference list checks from key articles were performed to identify additional sources.

Titles and abstracts of all retrieved studies were screened independently by two reviewers. Full-text articles were then assessed independently by the same reviewers to determine eligibility. Discrepancies were resolved through discussion or consultation with a third reviewer. No automation tools were used for screening.

Inclusion criteria: •

Studies involving adolescents (10–19 years) in Malawi or Ghana.

Exclusion criteria: •

Studies focusing exclusively on non-adolescent populations.

Data extraction was carried out independently by two reviewers using a standardized form. Extracted data included: study setting, design, sample characteristics, dietary diversity scores (DDS), prevalence of micronutrient deficiencies, food security indicators, and relevant interventions or policies. Disagreements were resolved by consensus or a third reviewer. No automation tools or contact with study authors was necessary to confirm or obtain missing data.

Primary outcomes included: •

Dietary Diversity Score (DDS)

Secondary variables included: •

Study design and quality

Where data were missing or unclear, we made assumptions based on study context or reported limitations, clearly documented during extraction.

The Joanna Briggs Institute (JBI) Critical Appraisal Checklists were used to assess the risk of bias in observational and cross-sectional studies. Two reviewers conducted independent assessments. No automation tools were used.

Studies were grouped based on shared characteristics such as outcome measures (e.g., micronutrient status), target population, and geographic region. These were tabulated to assess eligibility for thematic synthesis and ensure alignment with the review objectives.

Data were prepared for synthesis by standardizing outcome measures (e.g., converting prevalence to percentages) and managing missing statistics by imputation where necessary.

Study results were tabulated in evidence matrices showing author, year, country, sample size, design, dietary indicators, and key outcomes. Figures and tables were used to visually compare results across countries and indicators.

A thematic synthesis approach was used due to heterogeneity in outcome measures and methodologies across studies. Quantitative synthesis (meta-analysis) was not feasible. Themes were derived inductively and grouped into policy, dietary, and deficiency domains.

Due to data heterogeneity, subgroup comparisons were made descriptively (e.g., seasonal variations, intervention vs. non-intervention contexts). No meta-regression was conducted.

Sensitivity analysis involved comparing findings between high-quality and moderate-quality studies based on JBI scores. Exclusion of low-quality studies did not significantly alter synthesized themes.

Risk of bias due to missing or selectively reported results was minimized by including both peer-reviewed and grey literature. However, funnel plots and statistical assessments for reporting bias were not performed due to lack of meta-analysis.

The GRADE approach was not applied formally. However, reviewers qualitatively assessed confidence in evidence strength based on consistency, study quality, and relevance to policy and adolescent nutrition in Sub-Saharan Africa.

•

Studies focusing on populations outside the adolescent age range.

Data were extracted using a standardized form capturing key variables: study location, population characteristics, type and prevalence of micronutrient deficiencies, dietary diversity indicators, and any nutrition-related interventions or policy measures. A thematic synthesis approach was applied to identify patterns, policy gaps, and evidence trends across studies.

As this study is based on publicly accessible secondary data, no ethical approval was required. Nonetheless, all efforts were made to ensure accurate representation and proper citation of original sources.

This systematic review is limited by potential publication bias, heterogeneity in study design, and differences in dietary assessment methodologies. The restriction to English-language publications may also have excluded relevant studies published in other languages.

Adolescent malnutrition, especially from deficiencies in macronutrients, is a significant public health challenge in both Malawi and Ghana. These countries face a complex situation characterized by both undernutrition and overnutrition, often referred to as the double burden of malnutrition. This section examines the prevalence of malnutrition in these countries, focusing on anemia, underweight, stunting, and overweight, and explores the efforts by both governments to tackle these issues.

Figure 2 shows the prevalence rates of malnutrition among adolescents in Ghana and Malawi. In both Malawi and Ghana, anemia is a widespread issue among adolescents. In Malawi, approximately 35% of adolescent girls aged 15-19 years are anemic, ³² while in Ghana, nearly 50% of adolescent girls are affected. ³³ The high prevalence of anemia in these countries is primarily due to iron deficiency, inadequate dietary diversity, and other factors like malaria and parasitic infections. Anemia adversely affects physical health, cognitive development, and overall well-being, making it crucial for both countries to implement targeted interventions to improve iron intake and address the root causes.

Alongside anaemia, underweight remains a significant concern in both countries. In Malawi, around 13% of adolescent girls are underweight, ³² while in Ghana, 24.7% of adolescents aged 10-19 years are considered underweight, and 39.7% experience some form of undernutrition. ³⁴ Being underweight during adolescence can lead to developmental delays, weakened immune systems, and increased susceptibility to infections. Despite ongoing efforts, the persistence of underweight highlights the challenge of ensuring adequate nutrition during this crucial period of growth.

Stunting, which indicates chronic malnutrition during early childhood, is another major issue in both countries. A significant proportion of children under five years old are stunted in both Malawi and Ghana, indicating the long-term effects of poor nutrition that persist into adolescence. Stunting limits physical and cognitive development, which can affect academic performance and overall life outcomes. The high rates of stunting in these populations are often linked to inadequate micronutrient intake during childhood, underscoring the need for improved nutrition in early years.

In addition to undernutrition, overweight and obesity are increasingly becoming problems, reflecting the double burden of malnutrition. In Malawi, the prevalence of overweight among adolescent girls has risen, ³² a trend associated with urbanization and changes in dietary patterns. Similarly, Ghana has seen an increase in the number of overweight and obese adolescents, particularly in urban areas. This shift towards overnutrition is concerning because it raises the risk of future non-communicable diseases such as diabetes and hypertension.

Efforts to combat these forms of malnutrition are underway in both countries. In Malawi, the government has launched programs aimed at providing iron and folic acid supplements to adolescent girls and promoting nutrition-sensitive farming. ³² These initiatives focus on improving iron intake and dietary diversity. However, challenges remain in scaling these programs to reach all vulnerable groups. The government also emphasizes addressing the broader causes of malnutrition, such as poverty and food insecurity, through sustainable agricultural practices and better access to nutritious foods.

In Ghana, the government has introduced a National Nutrition Policy aimed at reducing malnutrition and improving dietary diversity across the population. ³⁵ This policy includes strategies for improving food security, providing nutrition education, and increasing access to essential micronutrients. Despite these efforts, gaps remain in reaching adolescents, especially those in rural areas who are at the highest risk of nutritional deficiencies. As with Malawi, addressing the root causes of malnutrition—such as poverty, food insecurity, and limited access to diverse and nutritious foods is critical for the success of these interventions.

Both countries also face significant issues with micronutrient deficiencies, including inadequate intake of essential vitamins and minerals like vitamins A, thiamine, riboflavin, folate, calcium, and zinc. In Ghana, adolescents are particularly deficient in these nutrients, which increases the risk of stunting and anemia. ³⁶ Low dietary diversity in both Malawi and Ghana restricts the intake of these essential micronutrients, making it clear that improving access to a variety of nutrient-dense foods is essential to combat deficiencies.

The double burden of malnutrition in both countries underscores the need for integrated strategies that address both undernutrition and overnutrition. Effective interventions should focus on nutrition education, promoting healthy dietary habits, and encouraging physical activity. Additionally, programs that improve food security and ensure access to nutritious foods, especially for rural and low-income adolescents, are crucial to tackling the root causes of malnutrition and ensuring better health outcomes.

Table 1 (refer to data availability section ⁵⁷ ) presents the summary of studies on dietary diversity among adolescents in Malawi and Ghana. Dietary diversity is a vital component of adolescent nutrition, influencing their growth, development, and overall health. ³² Studies conducted in Ghana and Malawi reveal significant challenges to achieving optimal dietary diversity among adolescents, with numerous socio-economic, cultural, and environmental factors contributing to these barriers.

In Ghana, a longitudinal cohort study of 416 pregnant adolescents found that more than half of the participants lacked adequate dietary diversity. Factors such as rural poverty, food insecurity, and cultural food aversions significantly impacted dietary intake, underscoring the difficulties faced by pregnant adolescents in rural areas. ³⁷ Similarly, a cross-sectional study of 137 rural adolescents (ages 10-14 years) revealed that 84.7% of adolescents had inadequate dietary diversity, which was attributed to meal skipping and excessive snacking. ³² This highlights the challenges in maintaining a balanced diet, especially among younger adolescents who may lack access to nutritious foods. Interestingly, a study during Ramadan showed that although dietary diversity increased (p < 0.001), meal frequency decreased (p < 0.001), resulting in weight loss (p < 0.001), illustrating how seasonal changes and fasting practices can further affect adolescent eating patterns. ³⁵ Further investigations into adolescent dietary patterns in Ghana found that school type influenced dietary diversity. A cross-sectional study of 236 adolescents revealed that only 22% of boarding students had adequate dietary diversity, compared to 64% of day students. ³⁸ This suggests that the school environment plays a significant role in adolescent nutrition, with boarding students potentially facing challenges in accessing a variety of foods.

Additionally, food variety scores were linked to income, calcium intake, and residential area, emphasizing that socio-economic factors significantly influence adolescent eating habits. ³⁹ Furthermore, maternal dietary diversity was found to be positively associated with child dietary diversity, indicating that improving maternal nutrition could have a direct positive effect on children’s diet quality. ⁴⁰

Among in-school adolescents in Ghana, 49.9% had healthy diets, though 93% consumed soft drinks and 90% ate sweets, reflecting unhealthy dietary habits prevalent among the youth. Additionally, 57% skipped breakfast, with gender, academic performance, and geographical location influencing dietary choices. ⁴¹ Food insecurity was another major issue, with 56.7% of adolescents reporting food insecurity at school and 53.5% at home, which was linked to poorer diet quality and reduced dietary diversity. ⁴² This suggests that addressing food insecurity in both school and home settings is crucial to improving adolescent nutrition.

In Malawi, the situation mirrored many of the challenges faced in Ghana. A cross-sectional study of 62 pregnant adolescents (ages 15-19) found that 69% of participants did not meet the minimum dietary diversity requirements. The consumption of meat, poultry, and leafy vegetables was positively associated with improved hemoglobin levels, highlighting the importance of diverse, nutrient-rich foods in supporting adolescent health. However, 35% of the adolescents adhered to food taboos, and 87% skipped food groups, further complicating efforts to improve dietary diversity. ⁴³ The issue of dietary diversity was also explored through Dietary Diversity Scores (DDS), which were found to correlate with the mean adequacy ratio (MAR) of 11 micronutrients during the preharvest season but not during the post-harvest season, indicating that seasonal agricultural cycles impact the validity of DDS as a measure of nutrient adequacy. ⁴⁴ A similar study in Malawi concluded that DDS should be used cautiously, as seasonality affects its accuracy.

Micronutrient deficiencies remain a significant concern among adolescents in both Ghana and Malawi, with widespread deficiencies in iron, zinc, vitamin A, and folate. In Malawi, iron-deficiency anemia affects approximately 40% of adolescent girls due to poor dietary intake and increased iron requirements during menstruation. ^{45– 47} Vitamin A deficiency remains prevalent due to limited consumption of vitamin A-rich foods such as eggs, dairy, and leafy vegetables. ^{45, 48} Zinc deficiency is also common, impacting adolescent immune function and growth. ^{48, 49}

Ghana exhibits similar trends, with iron-deficiency anemia affecting over 35% of adolescent girls and 20% of boys, primarily due to inadequate intake of bioavailable iron from animal sources. ^{50– 52} Inadequate folate intake among adolescents in both countries increase the risk of neural tube defects in future pregnancies, underscoring the need for improved nutrition among adolescent girls. ^{53, 54}

Table 2 presents a summary of studies on Micronutrient Deficiencies in Malawi and Ghana. The studies shows that Malawi and Ghana are still facing high rates of malnutrition, with an alarming prevalence of micronutrient deficiencies, particularly iron, zinc, and vitamin A, that contribute to anemia, stunting, and other health problems among adolescents. In Malawi, the prevalence of co-occurring overweight/obesity (OWOB) and micronutrient deficiencies is strikingly higher in urban areas compared to rural areas, as evidenced by a study from 2015-2016. ⁴⁵ Urbanization, which often accompanies socio-economic shifts, has resulted in a paradox where individuals are at risk of both undernutrition and overnutrition. This urban-rural divide in dietary patterns and nutrient adequacy is exacerbated by poor dietary diversity and limited access to fortified foods. In rural Malawi, the inadequacy of micronutrient intake, particularly of zinc, calcium, and selenium, is a significant concern, with over 50% of households at risk for these deficiencies. ⁵⁵ However, agricultural interventions such as biofortification are promising strategies that could alleviate some of these issues by improving the availability of essential nutrients.

Similarly, in Ghana, both adolescent girls and pregnant teens are at heightened risk of iron deficiency anemia, with studies revealing that over half of pregnant adolescents suffer from anemia. ⁵¹ The prevalence of anemia is notably high in rural areas, and dietary iron intake is insufficient, contributing significantly to poor hemoglobin levels. The consumption of iron-rich foods like meat and dark leafy vegetables was associated with improved hemoglobin levels (Walters et al., 2019), ⁴⁶ yet only a fraction of pregnant adolescents consumed iron supplements as part of antenatal care, signalling a gap in nutrition education and supplement uptake. This is compounded by socio-cultural factors, such as food taboos, which often limit dietary diversity and the intake of critical nutrients.

Micronutrient deficiencies, particularly in zinc and iron, are widespread in both countries. Zinc deficiency, which affects over 20% of the populations in Malawi and Ghana, has been linked to poor dietary intake and inadequate food security. ⁴⁹ Furthermore, inadequate zinc and iron intake contributes to poor cognitive function and increased vulnerability to infections, exacerbating the public health burden. In both Malawi and Ghana, rural adolescents are particularly vulnerable to micronutrient deficiencies, with limited access to diverse foods and healthcare services. A study in rural Ghana found that meal skipping and lack of knowledge about iron-rich foods were significant factors contributing to anemia. ⁵⁴ This finding underscores the importance of nutrition education and community-based interventions to improve dietary habits. Additionally, school-based interventions, such as iron and folic acid supplementation, have been shown to reduce anemia prevalence significantly, ⁵⁶ highlighting the potential of such programs in tackling micronutrient deficiencies in these settings. Despite the high prevalence of micronutrient deficiencies, the interventions studied have demonstrated varying levels of success. In Malawi, nutritional interventions with ready-to-use supplementary foods (RUSF) have shown some promising results, particularly in improving vitamin B12 and vitamin D status. ⁴⁷ However, for these interventions to be sustainable, they must be integrated into broader public health strategies that address food security, dietary diversity, and socio-economic inequalities.

Figure 3 shows how different factors contribute to poor nutrition and micronutrient deficiencies among adolescents in Malawi and Ghana. The diagram begins with the main contributing factors: food insecurity, limited dietary diversity, and lack of essential micronutrients. These are the core issues that make it hard for adolescents to get the nutrients they need for healthy growth and development. These challenges are made worse by several underlying issues.

Socioeconomic inequalities limit access to nutritious food, especially in rural areas. Many families depend heavily on agriculture, which is often seasonal and vulnerable to climate change. Climate variability—such as droughts and floods—disrupts food production and availability, making the food supply less stable and less diverse. The impact of these combined factors is serious. In Malawi, many adolescents suffer from long-term malnutrition and a lack of key nutrients like iron, zinc, and vitamin A. This is partly due to heavy dependence on maize, which lacks several essential micronutrients. Urban areas in Malawi show a double problem: some adolescents are overweight but still suffer from hidden hunger due to poor-quality diets. In rural areas, the situation is worse due to very limited food options and low intake of important minerals.