Menstruation is associated with dietary diversity among adolescent girls: the role of social eating norms and menstruation related norms from a mixed-method study in Bangladesh

Menstruation-related food restrictions are common among adolescent girls in low-and-middle-income countries and often limit their dietary diversity (DD). Despite having scholarly attention, little is known about adolescent girls’ DD during menstruation and how menstruation related norms influence on achieving minimum dietary diversity from the standpoint of social norm theory. The objective of this mixed-methods study examines the relationship between menstruation and DD, and whether menstruation-related norms moderate this relationship. Quantitative data were collected from 898 girls, while qualitative data were obtained from 20 interviews and 12 focus groups in Bangladesh. Women’s dietary diversity scale was used to assess DD, menstruation status was collected through self-reported information and menstruation-related norms measured with an adapted scale. Multivariable regression models were used to analyze the associations and examine the influence of menstruation norms on this relationship. Qualitative data were analyzed thematically, emphasizing the domains of social eating norms theory. Quantitative results showed that girls who had menstruated in the past 0–7 days had significantly lower dietary diversity than those that had onset of menstruation in the past 8 days or more (β = –0.61; 95%CI: –0.80, –0.42; p<0.001). This association was moderated by menstruation-related norms: girls with more restrictive norms were less likely to consume diverse diet (β = –0.10; 95%CI: –0.17, –0.02; p=0.001). Sensitivity analyses with binary dietary diversity confirmed these findings. Qualitative findings illustrate that girls navigate food restrictions through compliance, adaptation, and quiet resistance to eating norms. Some adhered to deeply embedded social expectations, while others—guided by personal beliefs and bodily cues—prioritized comfort, or symptom relief. Adolescent girls experience lower dietary diversity during menstruation, largely due to restrictive social norms and household food rules. Programs and policies should use behavior change communication to promote diverse foods and educate youth on the deleterious impacts of restrictive menstruation and eating norms.