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Making adolescent girls a priority, not an afterthought, in the global health debate

In global health, we talk a lot about neglected diseases like
onchocerciasis and schistosomiasis—serious ailments that most people have never
heard of. But a condition that everybody is perfectly aware of, malnutrition,
may be the most neglected health problem in the world—and it affects many more
people than any single disease.
” Melinda Gates wrote that in 2014 on “Impatient Optimists,” the official blog of her and her husband’s foundation.

She goes on to mention, malnutrition is more than just
hunger. It can also manifest in the form of overnutrition/obesity, and it can be
found in both developing and developed countries. Appropriate infant and child
feeding practices, particularly breastfeeding, is cited as an example of a
critical step that can be taken worldwide to reduce or eliminate malnutrition
among young children (Gates, 2014).

As we persevere in our quest for having healthy
babies, attention to the health of mothers has slowly gained momentum. There
are numerous programs and services worldwide for pregnant and lactating
mothers. Most are devoted to general health education, antenatal vitamin
supplementation, safe birthing, and ways to care for babies in the first one thousand days of life.

While I completely agree with the Gates Foundation and
the rest of the global health community on the urgency of this matter, I also
believe there remains a huge unmet need: improving the nutritional status of
adolescent girls before they
become the pregnant and lactating women to which the other services cater. Adolescent
girls are a vulnerable population that have been largely marginalized and
overlooked in global health. This is especially shocking considering that
adolescents make up one-sixth of the world’s population (UNICEF, 2016).

Recently, I was in India to learn about how and
where adolescent girls fit in to the whole public health nutrition story,
especially in rural areas.  My first
host, ICRISAT,
took me to various sites in Telangana that they work in, including Dokur
(Mahbubnagar district), Aurepalle (Ranga Reddy district), and some villages in
Mancherial district.  My second host, PRADAN, took me to various venues in
and around the Godda and Dumka districts in Jharkhand. At all locations, we
conducted focus groups with adolescent girls, ages 10-15 years old. Then I interviewed
several adults: women’s self-help group (SHG) leaders, SHG members with
adolescent daughters, fathers with adolescent daughters, grandmothers with
adolescent granddaughters, and anganwadi teachers. My goal was to
explore the existing knowledge, attitudes, and practices around food,
nutrition, and health.


During a focus group
discussion with adolescent girls (ages 10-15) in Poriayahat (Godda district,
Jharkhand). (Photo credit: Manan Pathak, PRADAN)

While it is irrefutable that malnutrition is
heavily tied to poverty and related indicators such as education and
employment, there is also a serious gender-based sociocultural component.  From a very early age, there are numerous disparities
in the care and nurturing that female children undergo compared to their male
counterparts (Duflo, 2012). For example, in most of the households I visited, I
saw that the males and elders would take their food first, and these adolescent
girls, along with their mothers, would often eat last.  In many instances, the share of food would be
far less, and many girls would resort to eating something else (usually a snack
or item that lacks nutritive value but provides empty calories) or simply go
without. Intra-household allocation and distribution of food and resources is
highly unequal, and has been partially implicated in the nutritional
deficiencies that we know to exist among women and girls in rural India.  As adolescent girls reach puberty and become
women in the eyes of society, the pressure to marry and bear children quickly
intensifies.  In that process, however,
critical nutritional needs for both the girl’s personal growth and cognitive development,
as well as her future child’s, are neglected (such as iron, folic acid, and

Ultimately, what we end up seeing is an
intergenerational cycle of malnutrition where undernourished adolescent girls
become undernourished mothers that give birth to low birthweight babies. The United Nations Administrative Committee
on Coordination Sub−Committee on Nutrition, in their “4th Report − The World Nutrition Situation: Nutrition throughout the
Life Cycle
perfectly diagrammed the cyclical nature of poor nutrition and
health outcomes:


Source: United Nations Administrative Committee
on Coordination Sub−Committee on Nutrition, 4th Report − The World Nutrition
Situation: Nutrition throughout the Life Cycle (2000).

As an outsider, it was interesting to me to hear
the girls talk about what they thought was healthy versus unhealthy foods, as
well as about cultural and dietary restrictions placed upon them for various
reasons. For instance, in some focus group discussions in Jharkhand, the girls
told me that they thought chicken, bananas, and yogurt were unhealthy, but that
samosas, soft drinks, and chaat were healthy. When asked why, they
mentioned how they thought if the food tasted good, then it must be healthy.  While they were knowledgeable about some
aspects of health and nutrition, such as hand washing with soap and that leafy
green vegetables are ‘good for you’, there were other basic health topics for which
they had very little knowledge.  For
example, for the most part, neither the girls nor their mothers or grandmothers
knew the reason or significance of puberty or menstruation, and the topic was taboo
enough that it was a bit challenging at times to openly discuss with the girls
or their female elders.  

The most alarming part of my visit was listening to
adults and adolescents in both Jharkhand and Telangana tell me that they do not
believe that the youth in their villages have poor nutrition or that there is
an issue with intergenerational malnutrition, stunting, or wasting in India.
Many of the parents said that they thought their girls appeared tired, but also
thought it was from sleeping odd hours or eating junk food. Nowhere in the
rhetoric was there talk about these kids’ diets or how that might be affecting
their energy levels.  I guess undernutrition
has become as ubiquitous as rice and roti.  With this normalization of nutrition
deficiencies, it may be very challenging indeed to make headway on addressing malnutrition
of adolescent girls.

And yet, according to the latest data, around 23%
of women (ages 15-49 years old) are underweight (BMI <18.5); with worse
rates in rural areas (IIPS, 2016). Additionally, 53% of women of childbearing
age (15-49 years old) have anemia, again with slightly higher rates in rural
areas than in urban. (NFHS-4). If we treasure what we measure, then it may be
revealing to learn: disaggregated data about adolescents (ages 10-19), and
girls in particular, is not readily available.  

How can we make these girls a priority rather than
an afterthought?  Who, what, and how can
we utilize existing channels to improve adolescent health and nutrition? This
is what I am hoping to explore further at TCI. After all, they are the future –
mothers, grandmothers, aunts, sisters, and hopefully someday, leaders. And it’s
about time they have a fighting chance.


Being silly after a focus group discussion with adolescent schoolgirls
in Dokur (Mahbubnagar district, Telangana). (Photo credit: Dr. Padmaja Ravula,

By Krystal

Krystal Rampalli, MPH, is a
second year Ph.D. student and a Tata-Cornell Scholar in the Division of
Nutritional Sciences
. Her research focuses on gender and nutrition of
adolescent girls in rural India.


E. (2012). Women Empowerment and Economic Development. Journal of Economic Literature, 50(4):
1051-79. Available here.

Gates, M. (2014,
November 18). One of the Most Neglected Health Problems in the World. Retrieved here.

Institute for Population Health Sciences. (2016). National Family Health Survey
-4, 2015-16 India Fact Sheet. Retrieved here

United Nations
Administrative Committee on Coordination Sub−Committee on Nutrition (ACC/SCN).
(2000, January). 4th Report − The World Nutrition Situation: Nutrition
throughout the Life Cycle. Retrieved here.

UNICEF. (2016,
June). Some 1.2 billion adolescents aged 10-19 years today make up 16 per cent
of the world’s population. Retrieved here.