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In Malawi and Ghana, limited dietary diversity and widespread micronutrient deficiencies among adolescents pose significant health challenges. These issues are largely influenced by food insecurity, poverty, and environmental changes. This narrative review examines the nutritional status of adolescents in both countries using data from peer-reviewed studies and policy documents. A systematic literature search was conducted across PubMed and Google Scholar for studies published between 2014 and 2025. The review focused on dietary patterns, micronutrient status, socio-economic influences, and policy responses. Findings reveal a double burden of malnutrition—undernutrition and rising overweight—especially among adolescent girls. In Malawi, 35% of girls aged 15–19 were anemic; in Ghana, the figure approaches 50%. Poor dietary diversity, food insecurity, and cultural factors contribute to high levels of iron, zinc, and vitamin A deficiencies. While school-based nutrition programs and micronutrient supplementation efforts exist, their impact is limited, especially in rural areas. In conclusion, adolescent malnutrition in Malawi and Ghana remains a public health concern, driven by dietary inadequacies and socio-economic disparities, despite ongoing nutrition interventions.\" } { \"@context\": \"http://schema.org\", \"@type\": \"BreadcrumbList\", \"itemListElement\": [ { \"@type\": \"ListItem\", \"position\": \"1\", \"item\": { \"@id\": \"https://f1000research.com/\", \"name\": \"Home\" } }, { \"@type\": \"ListItem\", \"position\": \"2\", \"item\": { \"@id\": \"https://f1000research.com/browse/articles\", \"name\": \"Browse\" } }, { \"@type\": \"ListItem\", \"position\": \"3\", \"item\": { \"@id\": \"https://f1000research.com/articles/14-1181\", \"name\": \"Adolescent Dietary Diversity and Micronutrient Deficiencies in Malawi...\" } } ] } Home Browse Adolescent Dietary Diversity and Micronutrient Deficiencies in Malawi... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Ndovie P, Chisapo GH and Martin A. Adolescent Dietary Diversity and Micronutrient Deficiencies in Malawi and Ghana: Exploring Nutritional Challenges and food security—A Systematic Review [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :1181 ( https://doi.org/10.12688/f1000research.164375.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Systematic Review Adolescent Dietary Diversity and Micronutrient Deficiencies in Malawi and Ghana: Exploring Nutritional Challenges and food security—A Systematic Review [version 1; peer review: awaiting peer review] Patrick Ndovie https://orcid.org/0009-0002-9108-2648 1,2 , Gift Herrings Chisapo https://orcid.org/0009-0008-2541-4492 1 , Aduah Martin https://orcid.org/0000-0002-6201-8412 3 Patrick Ndovie https://orcid.org/0009-0002-9108-2648 1,2 , Gift Herrings Chisapo https://orcid.org/0009-0008-2541-4492 1 , Aduah Martin https://orcid.org/0000-0002-6201-8412 3 PUBLISHED 29 Oct 2025 Author details Author details 1 Agriculture and Food Systems, Lilongwe University of Agriculture and Natural Resources Faculty of Natural Resources, Lilongwe, Central Region, 265, Malawi 2 Department of Human Nutrition and Health, Lilongwe University of Agriculture and Natural Resources Faculty of Natural Resources, Lilongwe, Central Region, 265, Malawi 3 Department of Agriculture, Regentropfen University College, Kansoe Bolgatanga, Ghana Patrick Ndovie Roles: Conceptualization, Data Curation, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Gift Herrings Chisapo Roles: Investigation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Aduah Martin Roles: Investigation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW This article is included in the Agriculture, Food and Nutrition gateway. Abstract Adequate nutrition is essential during adolescence to support physical growth, cognitive development, and metabolic processes. In Malawi and Ghana, limited dietary diversity and widespread micronutrient deficiencies among adolescents pose significant health challenges. These issues are largely influenced by food insecurity, poverty, and environmental changes. This narrative review examines the nutritional status of adolescents in both countries using data from peer-reviewed studies and policy documents. A systematic literature search was conducted across PubMed and Google Scholar for studies published between 2014 and 2025. The review focused on dietary patterns, micronutrient status, socio-economic influences, and policy responses. Findings reveal a double burden of malnutrition—undernutrition and rising overweight—especially among adolescent girls. In Malawi, 35% of girls aged 15–19 were anemic; in Ghana, the figure approaches 50%. Poor dietary diversity, food insecurity, and cultural factors contribute to high levels of iron, zinc, and vitamin A deficiencies. While school-based nutrition programs and micronutrient supplementation efforts exist, their impact is limited, especially in rural areas. In conclusion, adolescent malnutrition in Malawi and Ghana remains a public health concern, driven by dietary inadequacies and socio-economic disparities, despite ongoing nutrition interventions. READ ALL READ LESS Keywords Adolescent nutrition, Micronutrient deficiencies, Dietary diversity, Nutritional status Corresponding Author(s) Patrick Ndovie ( [email protected] ) Close Corresponding author: Patrick Ndovie Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Ndovie P et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Ndovie P, Chisapo GH and Martin A. Adolescent Dietary Diversity and Micronutrient Deficiencies in Malawi and Ghana: Exploring Nutritional Challenges and food security—A Systematic Review [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :1181 ( https://doi.org/10.12688/f1000research.164375.1 ) First published: 29 Oct 2025, 14 :1181 ( https://doi.org/10.12688/f1000research.164375.1 ) Latest published: 29 Oct 2025, 14 :1181 ( https://doi.org/10.12688/f1000research.164375.1 ) Introduction Adolescence is a critical period for growth and development, requiring adequate nutrition to support physical, cognitive, and metabolic changes. 1 However, in sub-Saharan Africa (SSA), particularly in Malawi and Ghana, dietary diversity and micronutrient deficiencies among adolescents remain significant public health concerns. These deficiencies are closely linked to broader nutritional challenges and food insecurity, exacerbated by socio-economic disparities, agricultural dependency, and climate variability. 2 – 6 Food security, as defined by the Food and Agriculture Organization (FAO), refers to reliable access to sufficient, safe, and nutritious food to meet dietary needs for an active and healthy life. 5 , 6 Yet, in both Malawi and Ghana, economic constraints, seasonal food shortages, and limited access to nutrient-dense foods continue to undermine adolescent nutrition. 7 , 8 In Malawi, food security is predominantly tied to smallholder agriculture, with maize serving as the dietary staple. 9 While maize provides essential carbohydrates, an overreliance on this single crop contributes to widespread micronutrient deficiencies, particularly in iron, zinc, and vitamin A. 10 Chronic malnutrition remains a major issue, with approximately 38% of children under five experiencing stunted growth due to inadequate nutrient intake. 11 Adolescents, who require higher nutritional intake during their growth spurts, are equally affected by poor dietary diversity, compounded by food insecurity caused by erratic weather patterns, economic instability, and post-harvest losses. 12 , 13 While interventions such as food fortification, school feeding programs, and community-based nutrition education have been introduced, access to diverse, micronutrient-rich foods remains limited. 14 , 15 Ghana, despite having a more diversified agricultural sector than Malawi, continues to face food insecurity and nutritional challenges, particularly in the northern regions where poverty and limited agricultural productivity persist. 16 The typical Ghanaian diet comprises cereals, tubers, legumes, and animal-source foods, yet iron-deficiency anaemia remains widespread, particularly among adolescents and women of reproductive age, due to inadequate consumption of iron-rich foods and poor dietary iron bioavailability. 17 , 18 Additionally, rapid urbanization has altered dietary patterns, leading to increased consumption of processed and convenience foods that lack essential micronutrients. 19 – 21 This shift has contributed to a dual burden of malnutrition, with both undernutrition and a rising prevalence of diet-related non-communicable diseases (NCDs), such as obesity, diabetes, and hypertension. 22 – 24 Dietary diversity is a key determinant of nutritional status and is essential for preventing micronutrient deficiencies and ensuring overall health among adolescents. Diets incorporating a variety of food groups—including fruits, vegetables, legumes, animal proteins, and fortified staples—can significantly improve nutrient intake. 25 – 27 However, in both Malawi and Ghana, multiple barriers limit dietary diversity, including economic constraints, cultural food preferences, and seasonal food availability. 28 Government-led programs such as Ghana’s Planting for Food and Jobs (PFJ) initiative and Malawi’s Scaling Up Nutrition (SUN) movement aim to enhance agricultural productivity and improve nutritional outcomes. 29 – 31 However, challenges such as inadequate funding, infrastructural limitations, and gaps in nutritional education hinder the effectiveness of these interventions. This systematic review aims to explore adolescent dietary diversity and micronutrient deficiencies in Malawi and Ghana within the broader context of food security and nutritional challenges. By synthesizing findings from peer-reviewed literature, government reports, and intervention programs, this review seeks to highlight the primary barriers to achieving optimal adolescent nutrition. Materials and methods Study design 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. Figure 1. PRISMA flow diagram showing the selection process for studies included in the systematic review. This PRISMA flow diagram illustrates the study selection process for the systematic review. It details the number of records identified, screened, assessed for eligibility, and included in the final review, along with reasons for exclusions. The process ensures transparency and rigor in identifying relevant studies on adolescent nutrition in Malawi and Ghana. Data sources and search strategy 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” • “Adolescent nutrition” AND “Ghana” • “Micronutrient deficiencies” AND “adolescents” • “Dietary diversity” AND “food security” AND “Sub-Saharan Africa” • “Iron,” “zinc,” “vitamin A,” “folate deficiencies” AND “adolescents” 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. Materials and methods Study design 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. Data sources and search strategy 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” • “Adolescent nutrition” AND “Ghana” • “Micronutrient deficiencies” AND “adolescents” • “Dietary diversity” AND “food security” AND “Sub-Saharan Africa” • “Iron,” “zinc,” “vitamin A,” and “folate deficiencies” AND “adolescents” 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. Study selection process 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 and exclusion criteria Inclusion criteria: • Studies involving adolescents (10–19 years) in Malawi or Ghana. • Studies examining dietary diversity, micronutrient deficiencies, or food security. • Peer-reviewed empirical research, systematic reviews, or policy/governmental reports with relevant nutritional data. Exclusion criteria: • Studies focusing exclusively on non-adolescent populations. • Articles lacking quantitative or qualitative data on dietary diversity or micronutrients. • Non-peer-reviewed literature unless from reputable organizations. Data extraction process 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. Outcomes and other variables Primary outcomes included: • Dietary Diversity Score (DDS) • Prevalence of micronutrient deficiencies: iron, zinc, vitamin A, folate • Food group consumption and frequency • Meal frequency and food taboos • Use of supplements (e.g., iron-folic acid) Secondary variables included: • Study design and quality • Participant demographics • Geographical setting • Intervention or policy presence • Funding sources Where data were missing or unclear, we made assumptions based on study context or reported limitations, clearly documented during extraction. Risk of bias assessment 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. Study eligibility for synthesis 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 preparation and management Data were prepared for synthesis by standardizing outcome measures (e.g., converting prevalence to percentages) and managing missing statistics by imputation where necessary. Tabulation and visualization 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. Data synthesis methods 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. Exploration of heterogeneity Due to data heterogeneity, subgroup comparisons were made descriptively (e.g., seasonal variations, intervention vs. non-intervention contexts). No meta-regression was conducted. Sensitivity analyses 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. Reporting bias assessment 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. Certainty of evidence 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. Exclusion criteria • Studies focusing on populations outside the adolescent age range. • Publications lacking specific data on dietary diversity or micronutrient status. • Non-peer-reviewed materials (e.g., opinion pieces), unless published by reputable organizations. Data extraction and synthesis 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. Ethical considerations 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. Limitations of the study 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. Nutritional status of adolescents in Malawi and Ghana 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. Figure 2. Nutritional status of adolescents in Malawi and Ghana. This diagram summarizes the nutritional status of adolescents in Malawi and Ghana, highlighting high rates of micronutrient deficiencies, anemia, stunting, and poor dietary diversity. Key contributing factors include poverty, food insecurity, and limited nutrition knowledge. These conditions negatively impact growth, cognitive development, school performance, and long-term health outcomes. 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. Dietary diversity among adolescents in Malawi and Ghana 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 among adolescents 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. Table 2. Summary of studies on micronutrient deficiencies and malnutrition in Malawi and Ghana. Country Year Micronutrient Study design Sample size Key findings Reference Malawi 2020 Iron Cross-sectional (2015–2016 Malawi Micronutrient Survey) 723 nonpregnant women (15–49 y) 10.8% of women had overweight/obesity and micronutrient deficiency; urban women had 2× higher prevalence than rural women. Rhodes et al . Malawi 2019 Iron Cross-sectional 62 pregnant adolescents (15–19 y) 66% were anemic, 69% lacked dietary diversity, and 74% had inadequate meal frequency. Antenatal nutrition advice increased iron supplement intake. Walters et al . Malawi 2018 Vitamin B12, Vitamin D, Zinc, Iron Randomized trial 343 pregnant women (moderately malnourished) Vitamin B12 and D deficiencies persisted despite supplementation; RUSF had the best outcomes. Glosz et al . Malawi 2015 Calcium, Selenium, Zinc Household survey analysis National-level data >50% of households lacked sufficient energy, Ca, Se, and Zn intake. Biofortification could reduce Se deficiency. Joy et al . Malawi 2024 Iron, Zinc, Vitamin A Cross-sectional (2015–2016 MDHS) 4618 mother-child pairs 5.5% had double burden (overweight & undernutrition); urban areas had higher prevalence. Khaki et al . LMICs (including Malawi) 2020 Zinc Systematic review 25 countries 68% of Malawian adolescents had low plasma zinc levels; urban women had higher deficiency rates than rural. Gupta et al . Ghana 2021 Iron (IDA) Prospective cohort 416 pregnant teenagers (13–19 y) 57.1% were anemic; hunger, low MUAC, malaria tablets, and low iron stores were associated with anemia. Annan et al. Ghana 2021 Iron Cross-sectional 151 adolescent females 50.3% were anemic; stunting was 26.5%; anemia impacted academic performance. Tandoh et al . Ghana 2021 Iron Cross-sectional 137 adolescents (10–14 years) Majority had low iron knowledge; chicken and dried fish intake reduced anemia risk. Wiafe et al . Ghana 2019 Iron, Zinc, Vitamin B6, Folate, Vitamin B12, Vitamin A Cross-sectional 438 school children (9–13 years) High micronutrient inadequacies; weak association between cognition and zinc/folate intake. Annan et al. Ghana 2023 Iron, Vitamin C Randomized Controlled Trial 100 adolescents (10–14 years) Nutrition education reduced anemia prevalence and improved dietary intake, except ferritin levels. Wiafe et al . Ghana 2021 Iron, Folic Acid Pre-post longitudinal evaluation 1387 schoolgirls (10–19 years) School-based IFA supplementation reduced anemia from 25.1% to 19.6%. Gosdin et al. Ghana 2020 Iron, Zinc, Folate, Calcium, Vitamin A Cross-sectional 379 pregnant women 56.5% anemia prevalence; higher in rural areas; low dietary diversity increased anemia risk. Ayensu et al . Ghana 2020 Iron, Zinc, Copper, Retinol, Vitamin D Cross-sectional 95 women (18–35 years) 23% food insecurity; weak association between food insecurity and micronutrient deficiencies. Pobee et al . Ghana 2020 Iron Cross-sectional 336 nulliparous women 41.5% were anemic; 34.5% had iron depletion, associated with younger age and region. Adu et al . Ghana 2020 Iron, Folic Acid Cross-sectional 404 adolescent girls 81% adhered to Iron and Folic Acid supplementation; 38.9% had Hb <12g/dl, indicating a \"medium\" anemia prevalence; strong anemia knowledge observed; need for stronger community education. Yidana et al. 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. Factors influencing adolescent micronutrient deficiencies in Malawi and Ghana 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. Figure 3. Pathway of micronutrient deficiencies and malnutrition in Malawi and Ghana: combating and exacerbating factors and impacts. This diagram shows how poverty, food insecurity, low dietary diversity, and poor health systems contribute to micronutrient deficiencies and malnutrition in Malawi and Ghana. These factors lead to anemia, stunting, and poor health outcomes, especially among adolescents and women, reinforcing intergenerational cycles of undernutrition and limiting human development. 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. Conclusion Adolescent malnutrition in Malawi and Ghana reflects a double burden of undernutrition and overnutrition, with high rates of anemia, stunting, underweight, and rising overweight. Micronutrient deficiencies, especially in iron, zinc, and vitamin A—are widespread due to poor dietary diversity, food insecurity, and socio-cultural barriers. While both countries have implemented policies and interventions, challenges remain, particularly among rural and low-income adolescents. Effective solutions require integrated approaches that promote nutrition education, improve access to diverse, nutrient-rich foods, and address the root causes of malnutrition. Strengthening school- and community-based programs is essential to improving adolescent health and breaking the cycle of malnutrition. Legend for table 1 (refer to data availability section 57 ) This table summarizes studies on dietary diversity among adolescents, focusing on Ghana and Malawi. It includes study design, sample size, data collection methods, and key findings. Most studies report inadequate dietary diversity, influenced by poverty, food insecurity, and low nutrition knowledge, with consequences for adolescent health, growth, and development. Registration and protocol The systematic review was not registered, and the protocol was not prepared. Availability of data, code and other materials Data from this study is available at: https://doi.org/10.17605/OSF.IO/Z6MFU . 57 License: CC-By Attribution 4.0 International References 1. Norris SA, Frongillo EA, Black MM, et al. : Nutrition in adolescent growth and development. Lancet. 2022; 399 (10320): 172–184. Publisher Full Text 2. Militao EMA, Salvador EM, Uthman OA, et al. : Food Insecurity and Health Outcomes Other than Malnutrition in Southern Africa: A Descriptive Systematic Review. Int. J. Environ. Res. Public Health. 2022; 19 (9). PubMed Abstract | Publisher Full Text | Free Full Text 3. 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Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 29 Oct 2025 ADD YOUR COMMENT Comment Author details Author details 1 Agriculture and Food Systems, Lilongwe University of Agriculture and Natural Resources Faculty of Natural Resources, Lilongwe, Central Region, 265, Malawi 2 Department of Human Nutrition and Health, Lilongwe University of Agriculture and Natural Resources Faculty of Natural Resources, Lilongwe, Central Region, 265, Malawi 3 Department of Agriculture, Regentropfen University College, Kansoe Bolgatanga, Ghana Patrick Ndovie Roles: Conceptualization, Data Curation, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Gift Herrings Chisapo Roles: Investigation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Aduah Martin Roles: Investigation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 29 Oct 2025, 14:1181 https://doi.org/10.12688/f1000research.164375.1 Copyright © 2025 Ndovie P et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Ndovie P, Chisapo GH and Martin A. Adolescent Dietary Diversity and Micronutrient Deficiencies in Malawi and Ghana: Exploring Nutritional Challenges and food security—A Systematic Review [version 1; peer review: awaiting peer review] . 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