Menstruation Is Associated with Dietary Diversity among Adolescent Girls: The Role of Social Eating Norms and Menstruation-Related Norms from a Mixed-Methods Study in Bangladesh

BACKGROUND: Menstruation-related food restrictions are common among adolescent girls in low-and middle-income countries and often limit their dietary diversity. Despite having scholarly attention, little is known about adolescent girls' dietary diversity during menstruation and how menstruation-related norms influence their ability to achieve minimum dietary diversity from the standpoint of social norm theory. OBJECTIVES: The objective of this mixed-methods study was to examine the relationship between menstruation and dietary diversity and whether menstruation-related norms moderate this relationship. METHODS: Quantitative data were collected from 898 girls and qualitative data were obtained from 20 interviews and 12 focus groups in Bangladesh. The women's dietary diversity scale was used to assess dietary diversity, menstruation status was collected through self-reported information, and menstruation-related norms were 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. RESULTS: Quantitative results showed that girls who had menstruated in the past 0-7 d had significantly lower dietary diversity than those who had onset of menstruation in the past ≥8 d (β: -0.61; 95% confidence interval: -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% confidence interval: -0.17, -0.02; P = 0.001). Sensitivity analyses with binary dietary diversity confirmed these findings. Qualitative findings illustrated that girls navigate food restrictions through compliance, adaptation, and quiet resistance to eating norms. Some adhered to deeply embedded social expectations, whereas others-guided by personal beliefs and bodily cues-prioritized comfort or symptom relief. CONCLUSIONS: 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 eating norms during menstruation.