Obstacles and opportunities for nourishing South Asia’s adolescent girls

Obstacles hindering operationalising regional nutrition frameworks

For decades the South Asian Association for Regional Cooperation (SAARC), an intergovernmental organisation through which the eight South Asian countries work together to tackle common issues, has acknowledged the need to improve adolescent girls’ nutrition and break the intergenerational cycle of undernourishment.6 In 1996, the SAARC ministerial meeting on children in South Asia called for commitment from member countries to address the root causes of child malnutrition, including the poor nutritional status and low social status of girls.7 In 2014, SAARC developed the Regional Action Framework for Nutrition,8 urging countries to implement policies, legal measures, and programmes to advance nutrition rights for adolescent girls. A decade later in 2024, SAARC reiterated its call to prevent malnutrition and provide nutritional care and support for at risk adolescent mothers.9

Despite these and other regional efforts, systemic barriers impeding policy and programme implementation continue to limit the potential of the regional commitments and frameworks.10 Sustainable development goal 2.2, targets ending all forms of malnutrition by 2030. With South Asia accounting for a substantial share of the global burden of infants born undernourished and undernourished girls who carry nutritional risks into motherhood, the region’s progress is vital for achieving global goals.

Gaps in adolescent nutrition policies and programmes

For the 172 million adolescent girls in South Asia to grow and develop to their full potential, they need access to nutritious foods, nutrition services, and positive nutrition practices. Evidence suggests programmes should include a package of 12 evidence based interventions across five areas11: fortified, nutritious meals; micronutrient supplementation and deworming; nutrition and lifestyle education; advertising, product labelling, marketing, and taxation policies that reduce consumption of unhealthy foods; and periodic nutrition screening and special social safety net services to women and girls who are mothers, underweight, or anaemic.1112 South Asia’s governments have worked to implement policies that align with these interventions, and by February 2025 five countries in the region (Bangladesh, Bhutan, India, Nepal, and Sri Lanka) had universally implemented programmes covering at least 6 of 12 interventions (see table 1 in web appendix).

Most countries are delivering interventions which ensure nutrition education and physical activity sessions happen in schools and provide children with school meals and essential micronutrient supplementation. However, not all policies targeting other interventions are being implemented, and policies regulating the food environment are conspicuously weak across the region. Some countries have policies on television advertising for unhealthy foods (n=5), taxation of unhealthy foods (n=7), front-of-pack nutrition labelling (n=3), and marketing or sale of unhealthy foods in and around schools (n=4). However, not all policies are translated into nationwide programmes. For example, only India and Sri Lanka have nationwide bans on the marketing and sale of junk foods in schools.

Moreover, there is little evidence that nutrition sensitive cash or food supplements for adolescent girls are consistently, systematically, and successfully reaching adolescent girls who are married, parenting, underweight, anaemic, or in geographically remote areas.13

Where programmes delivering all the 12 interventions do exist, successful and universal delivery is often constrained by systemic bottlenecks (web appendix table 2). In 2022, the government of Bangladesh launched a school based adolescent nutrition programme that delivers supplementation, counselling, and education services. Although workforce capacity constraints are being overcome through substantial financial investment in training education managers and schoolteachers, national scale-up and coverage has been constrained by inadequate financing for implementation support, leading to delays in procuring iron and folic acid tablets.14 In Pakistan, programmes promoting adolescent nutrition are in place in certain provinces or as pilots, but many are not yet delivered nationwide. The government has provided conditional cash transfers, alongside nutrition counselling, to over to 50 000 adolescent girls in six districts who are from families eligible for Pakistan’s flagship social protection programme (BISP). Despite success of the pilot, scale-up has been impeded by problems in coordination between the multiple partners involved in the project and in coordination between schools and the facilitation centres delivering the programme.14 Lastly, while several countries have a positive policy and programme environment to provide fortified nutritious foods in schools, school based nutrition programmes sometimes fail to ensure food quality, with some offering food provisions high in salt, sugar, and fat.15

Data gaps constrain aetiology driven programming

Several data gaps remain regarding the nutritional status of adolescent girls in South Asia. Data on the causes of anaemia and on dietary practices, including minimum dietary diversity and consumption of iron rich foods and fruit and vegetables, are limited across countries (web appendix table 3).3 Micronutrient deficiency prevalence data are rarely available for more than one time point, and data on important deficiencies such as vitamin A, vitamin D, and vitamin B₁₂ are not available for all countries in the region.3 Data are very limited on the coverage of nutrition intervention packages as part of routine programme monitoring systems. The variability in metrics and age groups covered; unavailability of raw data in certain countries; use of different terminologies, indicator definitions, reference data, and cut-off points; and data gaps in surveys covering the entire adolescent age group of 10–19 years complicate the interpretation of data trends between and within countries.3

Societal norms constrain girls’ access to nutritious food and services

Discussion of the difficulties faced in enhancing access to nutritious foods and establishing and delivering programmes that benefit adolescent girls must also address how deeply entrenched societal norms, shaped by patriarchy and local religious contexts, influence girls’ access to nutritious food, mobility, marriage, employment, and essential services.13 This gender discrimination manifests in numerous ways that affect nutrition security. For instance, dietary diversity among adolescents in South Asia is often limited, with diets primarily cereal based and low in iron rich foods.161718 Norms around family food consumption often prioritise men and boys, leaving women and girls to eat last and least. During menstruation, additional harmful practices exacerbate these challenges, including food restrictions, social isolation, and discouragement from engaging in physical activity and from attending school if appropriate hygiene measures are absent.11

Child marriage affects an alarming 26% of girls in the region.9 Three in four child brides give birth during adolescence, increasing risk of low birthweight infants, while young mothers face heightened risks of health complications themselves.219 In Afghanistan, extreme restrictions to voice, choice, and movement affect girls’ access to nutrition and healthcare.20

These societal norms not only undermine girls’ immediate access to nutrition and health services but also perpetuate systemic inequities that reinforce cycles of adolescent malnutrition. To break these cycles, interventions must address these deeply rooted norms as a fundamental step towards achieving gender equity and improving adolescent girls’ nutrition outcomes.

Tackling systemic bottlenecks for adolescent girls’ nutrition

Despite a relatively positive policy environment, systemic bottlenecks continue to hinder South Asian countries from improving adolescent girls’ nutrition. Drawing on the insights and actions proposed during a 2023 regional meeting of key stakeholders (box 1),12 targeted measures are essential to address these bottlenecks and ensure policies and programmes effectively meet the needs of adolescent girls.

Schools play a pivotal role in reaching adolescent girls, particularly as more girls are attending schools and continuing to secondary education. School based iron and folic acid supplementation programmes have been successfully scaled up regionally, with coverage in India increasing from 23% to 40% between 2017 and 2020, attributed to strengthened national coordination under the Anaemia Mukt Bharat strategy introduced in 2018.21 Schools across South Asia should now be equipped to provide an expanded package of interventions including regular nutrition screening, education, and supplementation.

Conducting a systems bottleneck analysis at national and subnational levels can help identify gaps in school based programmes and prioritise corrective actions. Identification of supply chain bottlenecks in India’s previous supplementation programmes led to prioritisation of improved budgeting and planning under the Anaemia Mukt Bharat programme.21 However, school based initiatives alone are insufficient. National programmes must ensure the inclusion of all girls, especially those out of school, adolescent mothers, and those in crisis affected areas. Social protection systems should prioritise these groups by offering targeted support, such as cash transfers and vouchers to improve access to nutritious foods and diets.

The food industry’s self-regulation has been largely ineffective in reducing adolescents’ exposure to junk food and unhealthy food environments. Government programmes are essential to hold industry stakeholders accountable but require strong leadership to implement.22 Sri Lanka is the first country in South Asia to bring in a specific tax on sugary drinks but faced strong resistance from industry lobbies and conceded to lower the tax by 40% a year after it was introduced.23 Governments must implement, enforce, and sustain strong policies on food labelling, advertising restrictions, and school food environments. Improved data on food exposure and programme coverage can further empower governments to protect adolescents from harmful food environments.

Reliable data are the foundation for designing and implementing effective nutrition interventions. Current data deficiencies prevent policy makers from tracking progress and identifying gaps. Nutrition surveys on the prevalence and coverage of nutrition interventions for adolescent girls aged 10-19 years are urgently needed, with indicators standardised across the region to allow comparisons and to unmask inequalities. For example, Sri Lanka carried out its second National Nutrition and Micronutrient Survey in 2022, five years after the first survey round, as part of a deliberate effort to ensure government micronutrient supplementation programmes among adolescents could be informed by up-to-date data.12 Regular monitoring of nutritional status is essential to support programme managers and policy makers to achieve national and global nutrition targets. Without addressing these data gaps, programmes are at risk of failing to achieve their intended impact.

Addressing the root causes of malnutrition requires tackling the gender norms and inequalities that perpetuate it. Nutrition policies and programmes must move beyond addressing the condition (eg, anaemia, underweight) and account for gender inequalities that both create and reinforce these conditions. Changing gender norms is challenging but essential. Partnering with feminist movements and female led organisations can amplify the voices of adolescent girls and position them as equal stakeholders in efforts to improve their wellbeing. Engaging men and communities can also create a positive environment to improve access to nutritious foods, nutrition services, and positive practices. Women’s collectives under Deendayal Antyodaya Yojana—National Rural Livelihood Mission (DAY-NRLM) in India, a poverty alleviation platform aiming to support and organise rural poor women, were found to help promote demand for quality nutrition services in the community and to facilitate access to social protections services, including food rations.1224 Such partnerships can drive progress towards dismantling the societal barriers that limit girls’ access to nutrition.

The challenges to improving adolescent nutrition in South Asia require clear action plans, stronger accountability mechanisms, and national and regional leadership. Although progress has been made in some areas, constraints in programme delivery, data availability, and systemic barriers remain.

To move forward, countries must scale up a comprehensive package of interventions across health, education and social protection systems, guided by human rights frameworks that emphasise the right to nutrition and health. Data deficiencies must be addressed, policy and legal frameworks strengthened for nutrition, and adolescent girls engaged not as passive recipients but as partners and influencers of change. By tackling these systemic barriers, South Asia can break the cycle of undernutrition and secure a healthier future for its adolescent girls.