Addressing systemic exclusion and gender norms to improve nutritional outcomes for adolescent girls in South Asia

Girls’ lower social positions can mean they eat last and least

Patriarchal norms in South Asia, perpetuated by both men and women, commonly prioritise the power, interests, and wellbeing of boys over girls. This preference is often exacerbated in families facing poverty, financial hardship, and food insecurity.5

In 2014, Bangladesh’s food security and nutrition surveillance project found that girls aged 10-16 years were more than twice as likely as boys to skip meals, consume smaller meals, or go to bed hungry because of household food insecurity.6 Additionally Bangladeshi adolescent girls from food insecure households were more likely than boys to have diets limited to rice, increasing their risk of nutrient deficiencies.6 More recent data are not available as these gender differences are not routinely monitored.

A 2023 qualitative study examining patriarchal food norms with nine Nepali girls aged 12-19 years also found that girls were often expected to sacrifice food for their families while boys were given preferential treatment as better economic investments.7 Moreover, girls often faced restrictions on eating outside the home as these environments were considered inappropriate for them and could lead to socially disapproved relationships.7

Child marriage and domestic violence also adversely affect food and nutrition outcomes among adolescent girls. Almost half of the world’s child brides live in South Asia, typically from households with lower wealth or education, rural areas, and particular religious backgrounds.8 While most countries, except Afghanistan and Pakistan, have laws against marriage of girls younger than 18 years, enforcement is weak and child marriage often persists as a result of dowry practices or as a means to reduce household expenses, including on food.1 Longitudinal data from Bangladesh show girl marriage is associated with intergenerational stunting and underweight among their children.9

In terms of violence against girls in South Asia, bidirectional associations have been found with nutrition outcomes. A 2016 study from Nepal found that lifetime experience of low intensity intimate partner violence (based on severity and frequency of violence) among women and girls was associated with a higher odds of overweight, and moderate intensity violence with underweight.10 Similarly, a study in Afghanistan (2016-17) found that intimate partner violence among females of reproductive age was associated with a 13% increased risk of food insecurity.11

Socioeconomic factors contribute to gender inequities

Adolescent girls in South Asia who experience marginalisation as a result of socioeconomic factors (ie, household income and wealth or parental education and occupation), ethnicity, religion, or rural residence, are often disproportionately burdened by malnutrition.4 The covid-19 pandemic worsened food insecurity and undernutrition, exacerbating existing inequities in malnutrition across South Asia.12 Between 2020 and 2021, adolescent hunger (10-18 years) in Bangladesh increased 2.5 fold, particularly among girls from the most vulnerable households (measured using 11 indicators), who were more likely to be hungry, consume fewer meals, and experience food restrictions.5 Analyses also suggest high and increasing incidence of excess weight and consumption of ultra-processed food among South Asian girls, but socioeconomic patterning is less clear as the region undergoes a nutrition transition.413

Importantly, efforts to advance women’s socioeconomic position can lead to more equitable and improved nutrition outcomes for their daughters. Studies in rural Pakistan using data from 2010-14 and 2018-19 showed that the economic empowerment of women (aged ≥20 years) was positively associated with food and nutrition security in their families.1415 Additionally, an intervention aimed at increasing women’s productivity and economic participation in nutrition sensitive agriculture initiatives resulted in enhanced diet diversity for women and children in India.16 Nevertheless, women struggled to generate income, probably because of limited access to land and decisions about agricultural work being predominantly controlled by men and in-laws.16 Patriarchal norms in many South Asian communities commonly consider economic, employment, and education opportunities for women and girls as unnecessary, given the expectation that they will primarily engage in unpaid domestic work.17

Valuing adolescent girls’ participation

South Asia contains some of the most gender unequal countries in the world, with Afghanistan, Pakistan, and India ranking 146th, 142nd, and 127th out of 146 countries.18 Adolescent girls are increasingly leading, or being called on to lead, movements to challenge patriarchal and oppressive social structures that minimise their opportunities to be leaders, hold professional or political roles, access services, and move freely. In Afghanistan, girls are using social media and international networks to lead movements against their exclusion from education, political and public life.19 Increased participation of girls in decision making is the focus of recent global youth movements, the UN sustainable development goal (SDG) on gender equality, and the Convention on the Elimination of All Forms of Discrimination Against Women (1979). The extent to which girls are given the opportunity to contribute to decision making on matters that affect them can vary, ranging from representation (the opportunity to be present and considered) and inclusion (equitable access to decision making spaces), to participation (actively influencing decision making processes).

However, despite all South Asian countries committing to global agendas to enhance girls’ participation in public life, evidence and real world examples are limited. In relation to girls’ participation in decisions about nutrition, where evidence exists, it often stems from local actions such as grassroots campaigns, peer, self-help, advocacy, and learning groups, and collaborations between governments and non-governmental organisations.2021 For example, at the state level, in Odisha, India, Unicef supported a programme aimed at promoting girls’ participation and empowerment across sectors and systems, including improved access to nutrition education. This initiative engaged a million girls, including those who were out of school and in rural areas.21

However, CARE International reviewed 73 global and regional reports on actions to address hunger in 2020, following the onset of the covid-19 pandemic, finding that women and girls were often overlooked and not prioritised by decision makers in 46% of the reports.22 Although the report was not specifically focused on the inclusion of South Asian adolescent girls, it signals the need for further empirical evidence to understand how to optimise adolescent girls’ decision making power around food and nutrition at national, regional, and global levels and the impacts of doing so.

Challenging systemic exclusion

A multifaceted approach, underpinned by better data monitoring, strategic nutrition action plans, scaling-up effective programmes, and advancing girls’ rights, is needed to catalyse improvements in adolescent girls’ nutrition in South Asia. Figure 1 shows the areas of action required to achieve these four priorities.

Fig 1

Priority areas of action to work towards better diets and nutrition outcomes for adolescent girls in South Asia23

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First, more robust and routine monitoring of gender inequities across all nutrition indicators is required to identify and prioritise actions to equitably improve nutrition for adolescent girls (10-19 years) across various sociodemographic and cultural groups in South Asia.4 Up-to-date national data are essential to inform nutrition policy and programmes and ensure accountability. Recognising this, Bangladesh’s food security and nutrition surveillance project has operated for more than two decades, providing government funded, nationally representative nutrition information for women and adolescent girls.24 In countries where national governments cannot prioritise resources to advance and refine nutrition monitoring, global and regional bodies can help bridge gaps.

For instance, the UN Women’s SDG indicator dashboard shows that gender inequities in food insecurity increased for South Asian females aged 15-49 years from 2015 to 2021, with the percentage experiencing food insecurity increasing from 48% to 86% in females compared with 43% to 73% in males. This platform could be extended to include adolescent specific data, disaggregated by sex, regions, and other sociodemographic factors.25 Similarly, improved reporting on nutrition related SDG indicators for adolescents could be enhanced across UN agencies (to complement routine data collection focused on mothers and young children). This could include integrating adolescent focused data into the annual report on the state of food security and nutrition in the world, the Unicef multiple indicator cluster surveys, and the WHO Global Health Observatory. But inadequate data must not stall strategic actions to tackle the systemic drivers of gender inequities.

Second, as all countries in South Asia have adopted nutrition specific (eg, school feeding programmes) or nutrition sensitive (eg, education and economic programmes) policies or plans,26 it is important to identify their gender equity potential and how they can be strengthened to directly benefit adolescent girls. For example, Bhutan’s national nutrition strategy and action plan for 2021-25 explicitly prioritises women of reproductive age, including by expanding the remit of current adolescent friendly health services to include nutrition services for adolescent girls. Similarly, the Government of India’s weekly iron and folic acid supplementation programme and Kishori Shakti Yojana (KSY) nutrition education and skills development programme target adolescent girls through schools and childcare centres, aiming to reduce anaemia.

Regional commitments under the South Asian Association for Regional Cooperation could also reinforce national leadership in prioritising strategic nutrition actions to reach adolescent girls. However, across the region, national nutrition actions are contingent on resources. Public and donor funds for nutrition specific actions vary, with countries such as Nepal, Pakistan, Afghanistan, and Sri Lanka increasingly reliant on international donors.26 To have impact and reach girls facing the most marginalisation because of poverty, ethnicity, disability, and geography, additional efforts are needed to sustain public and donor investment in gender transformative, adolescent focused nutrition policies and programmes across South Asia.

Third, where leadership from adolescent girls in nutrition and education programmes has been shown to have impact, often at the community level, resources should be allocated to continue to support their inclusion in delivering programmes. Indeed, gaps in community level delivery and impact have been thought to limit Bangladesh’s realisation of successive national nutrition plans over time.27 This aligns with global movements towards community empowerment and meaningful adolescent and youth engagement across sectors and levels, which have been facilitated through a WHO consensus statement.28 WHO emphasises supporting adolescents’ leadership through defined, paid, and influential roles, which can include adolescent girls participating in policy making or advisory committees, knowledge translation and advocacy networks, policy leadership and training programmes, and programme monitoring and evaluation.28

Across South Asia there are many examples of women and girls leading nutrition related change from which lessons can be drawn. SOCHAI (Social Changemakers and Innovators) is an example of a youth led social impact organisation in Nepal aiming to improve community nutrition by building entrepreneurial, advocacy, and research skills.29 SOCHAI has reached more than 5000 adolescents and young people, distributing nearly 7000 meals during the covid-19 pandemic. Similarly, Girl Powered Nutrition Sri Lanka has created strong networks of community actors and action hubs through the Sri Lanka Girl Guides Association. This initiative enables girls to speak about issues that affect them, supports their skill development, and harnesses their creativity in designing and delivering nutrition programmes. Girl Powered Nutrition also specifically aims to hold governments accountable for equitable nutrition between boys and girls.20

Community engagement, empowerment, and advocacy—especially as they relate to advancing youth leadership and gender equity—are core elements for scaling up effective nutrition action in the Scaling Up Nutrition (SUN) Strategy 2021-2025.30 Bangladesh, Nepal, Pakistan, Sri Lanka, Afghanistan, and several Indian states are members of the SUN movement.30 These countries have active SUN civil society networks to help drive change, alongside efforts to achieve country level leadership, adequate financing, and multisector collaborations for scaling up effective nutrition policies and programmes.

Finally, nutrition sensitive policies that economically support and protect girls should be priorities for governments in the region. Indeed, nutritional improvements in Bangladesh at the turn of the 21st century have been attributed to advances in girls’ education and employment outcomes, which have directly supported girls’ ability to make healthier food choices and indirectly improved their nutrition by delaying marriage and pregnancy.27 A recent policy review found that, with the exception of Afghanistan, all South Asian countries have policies to advance girls’ participation in education.26 In conjunction with increasing opportunities for girls’ education and employment, other policy efforts to improve nutrition should include ending gender based violence and the exploitation of girls by updating and enforcing marriage, religious, and family laws to be gender neutral, providing universal child benefits or cash transfers for families living in poverty, and creating financing initiatives (eg, credit and land access) that foster the economic advancement of girls across South Asia.31 These measures align with commitments that all South Asian countries have made to the UN Convention on the Rights of the Child and Convention on Elimination of All Forms of Discrimination Against Women. Ongoing challenges in upholding these rights indicate the need for additional research and political leadership to progress governance, accountability, and coordinated multisectoral mechanisms that can drive gender transformative policy implementation and shifts in cultural norms.30

Governments and actors across sectors must be accountable for monitoring gender inequities in nutrition and implementing gender transformative actions that disrupt underlying patriarchal and socioeconomic drivers of adolescent girls’ health in South Asia. Additional resources are also needed to support initiatives for and led by adolescent girls and women, advancing their participation in food and nutrition leadership roles that influence decisions for them, their families, their peers, and society.