www.thelancet.com Vol 399 January 8, 2022	 185
Series
Adolescent Nutrition 2
Food choice in transition: adolescent autonomy, agency,
and the food environment
Lynnette M Neufeld, Eduardo B Andrade, Ahna Ballonoff Suleiman, Mary Barker,Ty Beal, Lauren S Blum, Kathrin M Demmler, Surabhi Dogra,
Polly Hardy-Johnson, Anwesha Lahiri, Nicole Larson, Christina A Roberto, Sonia Rodríguez-Ramírez,Vani Sethi,Teresa Shamah-Levy,
Sofia Strömmer, AlisonTumilowicz, SusieWeller, Zhiyong Zou*
Dietary intake during adolescence sets the foundation for a healthy life, but adolescents are diverse in their dietary
patterns and in factors that influence food choice. More evidence to understand the key diet-related issues and the
meaning and context of food choices for adolescents is needed to increase the potential for impactful actions. The aim
of this second Series paper is to elevate the importance given to adolescent dietary intake and food choice, bringing a
developmental perspective to inform policy and programmatic actions to improve diets. We describe patterns of
dietary intake, then draw on existing literature to map how food choice can be influenced by unique features of
adolescent development. Pooled qualitative data is then combined with evidence from the literature to explore ways in
which adolescent development can interact with sociocultural context and the food environment to influence food
choice. Irrespective of context, adolescents have a lot to say about why they eat what they eat, and insights into factors
that might motivate them to change. Adolescents must be active partners in shaping local and global actions that
support healthy eating patterns. Efforts to improve food environments and ultimately adolescent food choice should
harness widely shared adolescent values beyond nutrition or health.
Introduction
Nutrition is central to adolescent growth and the realisation
of potential.1
Recent calls to address malnutrition in all
its forms among adolescents emphasise the importance
of multisectoral approaches to improve diets,2
but
programmatic action to do so across most countries is
woefully lagging. Adolescence is the time of transition
from primary dependence on caregivers to increasingly
diverse roles and responsibilities related to food
acquisition, preparation, and consumption, presenting a
uniqueopportunitytofosterhealthyeating.Yetadolescence
is not universal in its nature or duration across sociocultural
contexts.3
To foster healthy eating during
adolescence, an in-depth understanding of adolescent
dietary intake and food choice across different contexts is
essential.
These many contextual factors are depicted in this
Series’ conceptual framework,4
including natural, social,
cultural, political, and economic systems. For dietary
intake and food choice, these factors manifest in the
so-called food environment, defined as the point of
interaction of consumers with the food system, where
they make decisions about acquiring, preparing, and
consuming food.5–8
For the individual, this is captured in
the experience of availability, affordability, desirability,
and convenience of food.9
Throughout the day and over
time, adolescents might be exposed to varying food
environments, including home, school, workplace, and
formal and informal markets.
The aim of this paper is to elevate the importance given
to adolescent dietary intake and food choice, bringing
a developmental perspective to inform policy and
programmatic actions to improve diets. In the first
section, we illustrate the importance of the issue by
describing patterns of dietary intake among adolescents.
In the second section, we draw on existing literature to
map how food choice can be influenced by unique
features of adolescent development. In the third section,
we use pooled qualitative data combined with evidence
from the literature to explore the ways in which
adolescent development can interact with sociocultural
context and the food environment to influence food
choice, ending with a series of key considerations for
policies, programmes, and further research.
Current knowledge of dietary intake and
pattern among adolescents
A 2019 review from Europe, the USA, Canada,
Australia, and New Zealand found 13 surveillance
systems of adolescent diets but identified serious
limitations in data quality and comparability.10
A
2018 systematic review of dietary intake among
adolescent girls from low-income and middle-income
countries (LMICs) also highlighted critical gaps in data
and noted the absence of data for boys.11
Here we
explore three data sources to highlight current
knowledge of dietary intake patterns. First, we present
dietary data from adolescents in three countries,
purposefully selected to permit comparisons over time
and between countries (China and Mexico), and
variability among subgroups within a country (India).
Second, we use the Global School-based Student
Health Surveys (GSHS) to illustrate patterns of
consumption of select foods. Finally, we present a
global map of dietary data availability, generated from a
systematic review of scientific and grey literature
Lancet 2022; 399: 185–97
Published Online
November 29, 2021
https://doi.org/10.1016/
S0140-6736(21)01687-1
This is the second in a Series of
three papers on adolescent
nutrition
*All authors after the first author
are listed in alphabetical order
Global Alliance for Improved
Nutrition (GAIN), Geneva,
Switzerland (L M Neufeld PhD);
Brazilian School of Public and
Business Administration
(EBAPE), GetulioVargas
Foundation (FGV),
Rio de Janeiro, Brazil
(Prof E B Andrade PhD);
Department of Public Health,
California State University,
Sacramento, CA, USA
(A Ballonoff Suleiman DrPH);
NIHR Southampton Biomedical
Research Centre, University of
Southampton, Southampton,
UK (Prof M Barker PhD,
S Strömmer PhD); MRC
Lifecourse Epidemiology
Centre, Southampton General
Hospital, Southampton, UK
(Prof M Barker, S Strömmer,
P Hardy-Johnson PhD); School of
Health Sciences, Faculty of
Environmental and Life
Sciences, University of
Southampton, Southampton,
UK (Prof M Barker); Global
Alliance for Improved
Nutrition,Washington, DC,
USA (T Beal PhD, L S Blum PhD);
Global Alliance for Improved
Nutrition, London, UK
(K M Demmler PhD); Lancet
Standing Commission on
Adolescent Health and
Wellbeing, Noida, India
(S Dogra MA); Institute of
Economic Growth, New Delhi,
India (A Lahiri MTech); Division
of Epidemiology and
Community Health, University
of Minnesota School of Public
Health, Minneapolis, MN, USA
(N Larson PhD); Department of
Medical Ethics & Health Policy,
Series
186	 www.thelancet.com Vol 399 January 8, 2022
concerning dietary intake among adolescent boys and
girls (10–24 years of age) in all countries (249 countries
and territories in total) and all languages, collected
between January, 2010 and September, 2020. Further
details of methodology and results for all three data
sources are provided in the appendix (pp 1–9).
India’s Comprehensive National Nutrition Survey12
(cross-sectional survey from 2016 to 2018) assessed
frequency of consumption of nine food groups for
35 824 boys and girls. Representative samples by sex, urban
or rural residence, economic quintile, and state provide a
level of granularity rarely available in surveys. A
significantly higher proportion of adolescents in urban
areas and with higher economic status reported regularly
consuming nutrient-rich foods (eg, fruits or vegetables,
dairy, meat or eggs), but also nutrient-poor, energy-dense
foods (eg, sugar-sweetened beverages, fried foods, sweets)
as compared with their rural and lower economic status
counterparts (figure 1 and appendix p 2). Consumption
patterns, however, are highly variable by state (figure 2
and appendix p 2). This illustrates the importance of
subnational data for decision making, particularly for large
countries with substantial regional diversity, like India.
Repeat cross-sectional data from China (8 015 girls and
boys, 1997–2011) and Mexico (18 121 girls and boys,
2006–18) were analysed for five common dietary
indicators: fruit and vegetable intake (>400 g daily),
minimum dietary diversity (at least five food groups out
of ten), animal-source foods (percentage of energy
intake), ultra-processed foods (percentage of energy
intake), and sugar-sweetened beverages (at least once
per day). Significant positive time trends (eg, increased
dietary diversity and fruit and vegetable intake) were
found in China (p<0·01) but not Mexico (figure 3). In
Mexico, diets were already relatively diverse but also high
in ultra-processed foods and sugar-sweetened beverages
in 2006.
The GSHS currently provide the only methodologically
comparable source of dietary intake data for adolescent
boys and girls in LMICs. Using GSHS data, Beal and
colleagues13
previously highlighted several negative
dietary patterns, such as low consumption of fruit and
vegetables and high consumption of carbonated
beverages. We re-analysed GSHS data from 72 countries
to explore variability among and between countries and
regions, and sex variability within countries. Results
show substantial variability in consumption patterns
among adolescents across and within world regions.
Adolescents in only two countries (girls in Morocco
in 2010 and in Vanuatu in 2011) came close on average to
the often quoted five-a-day recommendation14
for
consumption of fruits and vegetables (appendix p 5).
Perelman School of Medicine,
University of Pennsylvania,
Philadelphia, PA, USA
(C A Roberto PhD); National
Institute of Public Health,
Cuernavaca, Morelos, Mexico
(S Rodríguez-Ramírez PhD,
T Shamah-Levy PhD); UNICEF
India, New Delhi, India
(V Sethi PhD); Bill & Melinda
Gates Foundation, Seattle,WA,
USA (ATumilowicz PhD); Clinical
Ethics and​Law at
Southampton (CELS), Primary
Care, Population Sciences and
Medical Education, University
of Southampton,
Southampton General
Hospital, Southampton, UK
(SWeller PhD); Institute of Child
and Adolescent Health, Peking
University School of Public
Health, Beijing, China
(Z Zou MD); National Health
Commission Key Laboratory of
Reproductive Health, Beijing,
China (Z Zou)
Correspondence to:
Dr Lynnette M Neufeld, Global
Alliance for Improved Nutrition,
1202 Geneva, Switzerland
lneufeld@gainhealth.org
Key messages
•	 Evidence of dietary intake among adolescents remains
insufficient for policy and programme decision making in
many countries. Future data collection efforts should always
include sex disaggregation, and disaggregation by
socioeconomic status and area of residence (rural or urban),
given persistent—and in some cases, increasing—
inequalities in many countries.
•	 Adolescence is a unique life stage, one during which
biological and social changes are rapid and profound,
but highly variable by context. Programmes must be
designed to this unique life stage and adjusted to the unique
contextual features that drive dietary intake and food
choice.They must have the potential to evolve in
approaches over the trajectory from 10 to 24 years of age
and account for the uniqueness of this trajectory across
contexts.
•	 Adolescents have a lot to say about why they eat what they
eat, and the factors that might motivate them to change.
Adolescents must be active partners in shaping local and
global actions that support healthy eating patterns. Efforts
to improve food environments and ultimately adolescent
food choice should harness widely shared adolescent values
and desire for social interaction around food.
•	 The current tendency towards celebrity and social media
influencers to advertise and promote nutrient-poor, energydense
foods must be reversed through regulation of social
media advertising and public pressure on celebrities.
•	 Autonomy and agency along withthe stronger desire for
uniqueness and belonging createsthe circumstancesthat
foster unhealthy diets in many modern and some mixed food
environment contexts. Harnessingthese factors to create a
sense of urgency regardingthe current state of food
environments could be a neededtrigger of change, but we
must work with adolescentsto do so—knowledge ofthe
importance of healthy foods alone will not bethattrigger.
•	 Adolescents living in poverty and food insecurity are keenly
aware of the precarity of their individual, family, and
perhaps community situations in relation to food. Many are
active participants in food production, preparation, and
income generation, in some settings in ways that put their
health and wellbeing at risk. Concerted efforts are urgently
needed to adapt social protection and income generation
efforts for adolescents, with their input.
•	 Current food environments across contexts are not
conducive to healthy food choice. In many contexts,
nutrient-dense foods are insufficiently accessible whereas
nutrient-poor, energy-dense foods are too readily available,
inexpensive, and often socially alluring.While working on
the regulatory and other actions to support sustainable
change, a bottom-up approach is needed. Adolescents can
be empowered with knowledge, skills, and motivation to
navigate towards a healthy and socially appealing diet.
Understanding of how to make nutritious foods more
desirable is urgently needed.
See Online for appendix
Series
www.thelancet.com Vol 399 January 8, 2022	 187
Conversely, adolescents in most countries are, on average,
consuming carbonated beverages at least once a day
(appendix p 6) and fast food at least once a week
(appendix p 7). Sex differences within regions or economic
classification were not statistically significantly different.
The systematic review revealed that some evidence on
dietary patterns among adolescents is available for
154 (62%) of all 249 countries (figure 4). Only 28 countries
(11%) have detailed food intake data at national or
subnational level that would permit assessment of, for
example, nutrient adequacy, analogous to the examples
from China and Mexico (dark green on map). Almost half
of these (46%) are high-income countries, and
predominantly in the Americas (36%), Europe (29%), and
Asia (29%). An additional 104 countries (42%) have
nationally or subnationally available evidence but only for
selected foods or food groups (light green on map),
analogous to the GSHS data. Several countries had
evidence from smaller studies for detailed food intake
(eight countries [3%]; red on map), or only selected foods
or food groups (14 countries [6%]; orange on map). Of the
717 papers identified, the majority (410 [57%]) present data
that cannot be disaggregated by sex, five (1%) present data
for boys only, and 45 (6%) present data for girls only.
In summary, nationally representative detailed dietary
intake data are still scarce, particularly with the
granularity necessary to characterise dietary patterns
among subgroups (like in India), or over time (like in
Mexico and China). The systematic review, however,
revealed a surprising amount of extant dietary data that
have not been fully analysed and synthesised in published
form. Nevertheless, data are particularly scarce in some
world regions, most notably Africa, and a substantial
proportion of available data cannot be disaggregated by
sex, something that urgently needs to be addressed. Such
data generally do not provide insights into the proportion
of adolescents choosing to adopt dietary patterns that
might emphasise or exclude specific food groups
(eg, vegan or vegetarian). Despite limitations, these data
and the published evidence highlight the need to address
diet quality among adolescents globally. To do so requires
an understanding of the forces that influence adolescents’
food choices.
Food choice at the intersection of adolescent
development, sociocultural context, and the
food environment
Story and colleagues15,16
explain adolescent dietary
behaviours using a model drawing on social cognitive
and ecological theory. Analogous to the conceptual
framework of this Series,4
food-related behaviour is
Figure 1: Prevalence of intake at least once per day (except as indicated) of
different food groups among Indian adolescents (2016–18)
Error bars show 95% CIs.The p values are for differences between subgroups.
Q=quintile.
Meat or eggs
(≥3 times per week)
Unhealthy food
(≥3 times per week)
Dairy
Fruits or other
vegetables
Dark green leafy
vegetables
Pulses or beans
Meat or eggs
(≥3 times per week)
Unhealthy food
(≥3 times per week)
Dairy
Fruits or other
vegetables
Dark green leafy
vegetables
Pulses or beans
Meat or eggs
(≥3 times per week)
Unhealthy food
(≥3 times per week)
Dairy
Fruits or other
vegetables
Dark green leafy
vegetables
Pulses or beans
p<0·01
p<0·001
p<0·001
p<0·001
p<0·001
p<0·001
p<0·001
p<0·001
p<0·001
p<0·001
p<0·001
p<0·001
p<0·001
p<0·05
0 10 20 30 40
Prevalence (%)
50 60 70 80 100
Boys
Girls
Urban
Rural
Q1 (poorest)
Q2
Q3
Q4
Q5 (richest)
Series
188	 www.thelancet.com Vol 399 January 8, 2022
explained as a reciprocal interaction across four levels of
factors: individual (psychosocial, neurodevelopmental,
biological, lifestyle); social environmental (family, peers);
physical environmental (community setting); and macro
systems (eg, media and social or cultural norms). As
adolescents age, their food-related behaviours shape and
are shaped by the interaction among these factors.15
The
contexts in which adolescents live, however, are diverse
and highly dynamic, as is their level of autonomy and
agency17
and the process of identity development.18
The
framework developed by Story and colleagues draws
mainly on data from the USA, and although the four
levels are probably applicable across contexts, the balance
and interaction among them at different points in the
developmental trajectory and across cultural and social
contexts is likely to be highly variable. Rights, roles, and
responsibilities also transition markedly across the
adolescent period,19,20
and the trajectory of that transition
differs among sociocultural contexts.21
For example,
timing of life events (eg, school completion, marriage,
pregnancy) varies substantially across social and cultural
contexts, profoundly affecting interactions with the food
environment at varying ages and developmental stages.
For some adolescents, rapid transitioning from childhood
to adulthood expands their roles to being carers for
younger siblings or elderly relatives, or to becoming a
spouse or parent. This changes who purchases and
prepares their food, when and with whom they eat, and
what priority they are given in accessing nutritious
foods;22,23
in some contexts, these changes are determined
by gender. Finally, several aspects of adolescent biological
and social development can create unique opportunities
and vulnerabilities related to food choice and influence
longer-term eating habits and food preferences.
The onset of puberty initiates a concert of biological
and neurodevelopmental transitions that can affect and
be affected by nutrient intake and food choice. Rapid
physical growth coupled with sexual maturation
increases nutrient requirements, and whether these
requirements are met affects biological development,
growth, long-term health, and longevity.1,24,25
Simultaneous
neurodevelopmental changes influence motivations and
behaviours, including dietary patterns. During adolescence,
brain remodelling and increased testosterone are
associated with heightened sensitivity to social evaluation
and influence, increasing the desire for autonomy and
motivation for risk-taking to gain social status and
recognition.19,26,27
Some studies suggest that reward
processing systems, which are remodelled during the
adolescent period, might become more sensitive to and
increase the appeal of energy-dense foods.28,29
Increased
sensitivity to social evaluation and threats to social status,
coupled with the development of physical secondary sex
characteristics, contribute to new awareness of body
image and might be accompanied by associated dietary
changes.30
This heightened identity and social sensitivity17
can also lead to increased awareness of one’s food habits
and those of peers, family, and other social groups.31
Neurodevelopmental changes motivate adoles­cents to
seek not only autonomy32
but also belonging, which
might promote eating habits that differentiate from
family and assimilate to valued social groups and norms.
Adolescence presents unique opportunities to foster
healthy food choice and the formation of longer-term
healthy dietary habits.33
Throughout the life course, the
Figure 2: Prevalence of intake at least once per day (except as indicated) of different food groups among
Indian adolescents (2016–18) by state
Pulses or beans Dark green leafy vegetables
Fruits or other vegetables Dairy
Meat or eggs (≥3 times per week) Unhealthy food (≥3 times per week)
<10% 10−19% 20−29% 30−39% 40−49% ≥50%
Series
www.thelancet.com Vol 399 January 8, 2022	 189
locus of control of many actions, including food-related
behaviours, moves from full dependency on caregivers
during infancy, to the individual and the family unit during
adulthood. The process and timing of that transition
depends on age, context, cultural and religious norms, and
economic and other factors.21
Similarly, the balance of
individual versus collective (eg, family) considerations,
including the fundamental meaning of autonomy, can
vary across cultural contexts.34
These unique features of
adolescence and their interaction with contextual diversity
have not been adequately studied, and raise questions on
the role of autonomy and agency in food-related decisions
across contexts. There is much discussion and debate in
the literature about the meaning of autonomy and agency,
a review of which is beyond the scope of this paper. For our
purposes, we distinguish between the autonomy to make
decisions (which requires economic and informational
resources, mobility, and opportunity) and agency (which is
the ability to act on such decisions);35,36
both are explored in
the following analysis.
An exploration of influences on adolescent
dietary intake and food choice
We explored influences on adolescent food choices using
a pooled analysis of qualitative data from 11 studies with
adolescents and adult informants from eight countries
(Bangladesh, Côte d’Ivoire, England, Ethiopia, India,
Indonesia, South Africa, and The Gambia). For each
study we classified context as a traditional, mixed, or
modern food environment based on the criteria of the
High-Level Panel of Experts on Food Security and
Nutrition8
(for details, see appendix p 10 and pp 15–18).
This was complemented by a literature search for
publications (PubMed and grey literature with cross
referencing) reporting adolescents’ perspectives on their
food choices (for search strategies see appendix p 22).
Studies in the pooled analysis varied in objectives and
methods,37–40
but all focused on speaking with adolescents
and adult key informants about diet and food choice.
Data were analysed using a novel breadth-and-depth
method designed for large-scale qualitative data analysis41
(for details, see appendix pp 10–12). This iterative process
has four steps: (1) construction of a composite dataset;
(2) using a computational text-mining tool to explore
word frequencies, concordance, co-location, proximity,
and salience (breadth); (3) preliminary analysis of a large
volume of short data extracts with concepts identified in
step 2 to explore how they address the research questions;
and (4) detailed thematic analysis of the sampled data
(depth).
Integrating results from the pooled analysis and
published literature and building on the Series’ conceptual
framework,4
figure 5 provides our interpretive summary of
the evidence describing the interaction of adolescent
autonomy, agency, and food environments on food choice.
Although adolescents have autonomy and express agency
across all food environments, their centrality to food choice
is much stronger in modern than traditional food
environments. In the latter, there was a consistent narrative
of family and community priorities often superseding
individual considerations, which was absent in modern
food environments. Second, although availability, affordability,
and desirability of food emerged as drivers of
adolescent choice in all three food environments, their
relative importance varied. The concept of affordability
also took on different meaning, reflecting value for money
in modern food environments, rather than the explicit lack
of financial resources to pay identified in traditional ones.
Convenience was evident in the narrative of adolescents
from modern and mixed food environments, and absent
in traditional ones. Across all food environments, more
than its healthiness or tastiness, food was valued for its
role as part of sharing in social time with friends, and in
some contexts, with families. Each country for which
Figure 3:Trends in the proportion of Chinese (n=8 015; age 10–19 years) and Mexican (n=18 121; age
12–19 years) adolescents consuming select dietary factors
Error bars show 95% CIs. China: bivariate linear regression. Mexico: smoothing splines. r=Pearson’s correlation
coefficient (p<0·01). Shaded area represents overlapping years.
China
1997 2004
Year Year
2011
0
20
40
Proportionofstudypopulation(%)
60
80
100
r=0·99
r=0·90
r=0·96
r=0·89
r=0·60
Mexico
2006 2012 2018
Fruits and vegetables (>400 g daily)
Minimum dietary diversity (≥5 food groups)
Animal-source foods (percentage of energy intake)
Ultra-processed foods (percentage of energy intake)
Sugar-sweetened beverages (at least once per day)
Series
190	 www.thelancet.com Vol 399 January 8, 2022
evidence was available had many unique features, but
grouping sites by food environment, and drawing on
published literature, illustrated common themes with
important implications for policies and programmes to
foster better diets among adolescents.
Traditional food environments
Adolescents living in poverty and food insecurity are keenly
aware of the precarity of their individual, family, and perhaps
community situations in relation to food
The literature review yielded few studies from traditional
food environments, all from contexts of extreme poverty
and from geographically isolated regions within each
country. The discourse across all contexts (Ghana,
Tanzania, Malawi;42
Kenya;43
Uganda44
) focused on hunger
and the intersection of food insecurity, climate, and
coping strategies to mitigate hunger. Adolescents from
the five countries lamented the lack of rain leading to
poor harvests and elevated rates of livestock deaths.
Coping strategies led to income-generating activities that
put health and wellbeing in danger, including
transactional sex reported by girls in Tanzania42
and
Kenya,43
heavy labour among boys and girls in Uganda,44
and selling alcohol in Kenya and Uganda. Abusing
alcohol and other substances to suppress hunger was
also reported.43,44
A cohort study in Ethiopia presents a
compelling narrative of how food insecurity drives many
life decisions for adolescents, but also highlights the
central role of community.45
Adolescents and adults in the traditional food
environments from the pooled analysis also spoke about
food as a basic need. They made a link between eating
well and having a healthy body and mind and felt that
both underweight and overweight were unhealthy.
However, both adolescents and adults reported limited
availability and affordability of healthy foods and, in
some sites, felt that their food supplies were threatened
by drought.
Food choice is an expression of agency, exercised in moments of
autonomy
Adolescents in the pooled analysis described seeking
places with friends between the supervised spaces of
home and school. Adolescents often reported sharing
food in these spaces and pooling money to purchase food
outside of home or school. Girls described less freedom
than boys, identifying earlier transition to adult roles
Figure 4: Availability of evidence regarding dietary intake
Quantitative, national, full diet
Semi-quantitative, national,
select foods
Quantitative, subgroup(s), full diet
Semi-quantitative, subgroup(s),
select foods
No data
Figure 5: Interpretive summary of key findings from the pooled qualitative data and literature review of
influences on food choice among adolescents
*Higher reported importance. †Moderate reported importance. ‡Lower reported importance.
Modern
• Desirability*
• Convenience and affordability†
• Availability‡
Mixed
• Availability, desirability and
affordability†
• Convenience‡
Traditional
• Availability and affordability*
• Desirability‡
Food choice
and dietary intake
Autonomyandagency
“We don't get root vegetables
or fruits that often…only once a month”.
(Girl, rural India)
“Families don’t get to buy them always…even if
they buy, I may feel like not eating these foods.
We can’t buy mango, jackfruit all the time”.
(Boy, urban Bangladesh)
“All your friends are having like, another chocolate
bar or packet of crisps all the time, you’re gonna
want to like buy a chocolate bar”.
(Boy, urban UK)
Series
www.thelancet.com Vol 399 January 8, 2022	 191
and, for some, early marriage. Even in the more resourceconstrained
environments, food was still one way in
which adolescents exercised some autonomy (eg, by
choosing not to consume the food, as reported by one
participant in Abidjan, Côte d’Ivoire). In the five studies
from the literature, more than individual autonomy,
adolescents emphasised their critically important roles in
the production, acquisition, and preparation of foods for
themselves and their families.
Implications for policy and programmes in traditional food
environment contexts
Evidence from traditional food environments that has
captured adolescent voices describing why they eat what
they do is scarce. Several published studies and our
pooled analysis provide a strong and consistent picture of
the profound effects of poverty, resulting in transition to
adult roles at young ages. Community and household
reliance on adolescents for income to purchase food is
likely to be limiting their educational opportunities.
Social protection that safeguards against food insecurity
is vital and could be linked to age-appropriate and
context-appropriate education opportunities for young
people, including training in agriculture and other skills,
and to employment opportunities. Programmes should
engage adolescents as agents of change to overcome
barriers to better diets, leveraging the social aspect of
food sharing; the strength of family and community
commitment expressed by many adolescents; and their
critical roles in the production, acquisition, and
preparation of food.
Mixed food environments
Being healthy is desirable for adolescents but not a strong
motivator of food choice
In our pooled analysis, adolescents expressed concerns
over food hygiene and the introduction of non-food items
into food (eg, plastics) more than its nutrient content.
Being underweight and overweight were both associated
with poor health, but some girls from Bangladesh
described being “fat” as healthier than thinness. By
contrast, in previously published studies from
Bangladesh,46
Guatemala,47
Morrocco,48
India,49
and Iran50
(as examples), adolescent girls reported reducing food
intake as a result of heightened awareness of body image
and a desire to control weight.
Disruption in meal patterns, particularly skipping
meals, was a finding across the published studies
reviewed from mixed food environments.46–48,50–53
Many
adults expressed concerns about a trend towards
adolescents rejecting traditional, home-cooked foods,
and favouring unhealthy snack foods, feeling that this
indicated that adolescents did not understand the
importance of a healthy diet. By contrast, many
adolescents said they understood what healthy meant but
did not find the idea of being healthy motivating in
relation to food choice. Interestingly, in the published
literature, nearly all adolescents asked to delineate
between healthy and unhealthy foods described foods
consumed at home, typically including many more fruits
and vegetables, as healthier. However, like our pooled
analysis findings, such knowledge did not necessarily
translate into consumption of healthier foods.54
Socioeconomic disparity is still an important driver of
access to nutritious food in mixed food environments
(eg, India55
).
Consuming food with friends outside the home is part of a
social ritual, brings a sense of belonging, and demonstrates
agency and autonomy from one’s family, by actively making
food-related decisions
In mixed as compared with traditional food
environments, adolescents emphasised food’s social
significance more and mentioned food as a basic need
less. Adolescents in the pooled analysis reported often
choosing to spend the small amount of money they had
on food and snacks, which, consistent with the published
literature,46,47
were widely available and cheap. Sharing
food with friends was part of social occasions and
reflected a growing sense of identity and autonomy. In
the pooled analysis, girls from Jakarta reported using
social media as a means to share information about
“cool” hang-out places and where to find good food.
Adults in that context expressed concern about new food
outlets and unhealthy products that were packaged and
priced to attract adolescents. In some settings, however,
girls mentioned being denied opportunities to be out
because it was culturally inappropriate and risked
eliciting social disapproval.
Food becomes more imbued with social status in the
literature describing mixed food environments.
Qualitative evidence from Brazil and Ethiopia suggests
that dietary variety serves both signalling and social
integration purposes.56
In India, non-traditional foods
(eg, pizza) were considered prestigious,57
and consuming
them reflected adolescents’ aspirations to advance
themselves economically and be more modern than the
previous generation.58
The role that commercial
advertising (traditional and social media) might play in
this regard is not well studied outside of high-income
countries. Food choices can help to fulfil adolescents’
newfound autonomy and agency,51
but also their desire
for both uniqueness and belonging.59
Several studies,
however, highlighted that adolescents still value meals at
home.46,50
For example, in Iran, adolescents preferred
eating home meals because of the “emotional atmosphere
of eating with family members”, as well as the safety and
security of ingredients.50
Implications for policy and programmes in mixed food
environment contexts
Populations are highly diverse in mixed food environments,
and in lower-income populations, adolescents’
experience can be much like that of traditional food
Series
192	 www.thelancet.com Vol 399 January 8, 2022
environments. Our analysis, however, provides a
consistent picture of food environments in transition,
with increasing availability and affordability of nutrientpoor,
energy-dense, and in some contexts, unsafe foods.
Concerted efforts are needed to curb this tendency. The
Brazilian National School Meals Program (PNAE),
offering free healthy meals in public schools, illustrates
how programmes can mitigate socioeconomic disparity in
nutritious food access. At-school eating among adolescents
attending PNAE-participating schools is significantly
healthier (ie, associated with lower consumption of
industrialised or ultra-processed salty foods and soft
drinks) than at-school eating among their peers from nonPNAE-participating
schools (eg, private schools).60
Programmes must work with adolescents, recognising
their autonomy and leveraging their agency to reverse the
shift that has led to nutrient-poor, energy-dense foods
embodying positive attributes. Many adolescents continue
to value meals at home and empowering them with skills
to make nutritious foods delicious and appealing can be a
force for improving the quality of diets.
Modern food environments
Knowing what healthy food choices are does not necessarily
lead to healthier choices
In the single modern food environment site from the
pooled analysis (England), adolescents described
healthy foods as helping to maintain present and
future health and supporting overall wellbeing. Salt
and fat were discussed in relation to less healthy food,
and protein and macronutrient balance in relation to
healthy diets. Adults felt that adolescents knew they
should eat healthy foods but did not behave accordingly,
sometimes leading to conflicts about food. Some
adolescents described trying to eat better (eg, more
fruit and vegetables, fewer sweets, less fried fast food)
but said that they faced temptation when people
around them ate less healthy foods. The abundant
literature on adolescent food choice in modern food
environments similarly identifies some level of
knowledge related to healthy foods, but also that this
knowledge might not be an important driver of choice.
In the pooled analysis, value for money was a primary
reason for buying foods that adolescents acknowledged
to be less healthy.
The literature and our pooled analysis illustrate that in
modern food environments, adolescents have ample
freedom and purchase some of their daily food (often a
substantial proportion) in these unsupervised spaces.
Gender did not notably determine freedoms or food
choices. Evidence from the USA,61,62
Canada,63
Ireland,64
England,65,66
Australia,67
and Spain68
(as examples) suggests
that the proximity to schools of shops and prepared food
outlets selling relatively inexpensive nutrient-poor,
energy-dense foods favours their regular consumption.
Although some studies did not find associations between
the proximity of unhealthy food environments to schools
and the dietary intake69
or bodyweight70
of adolescents, in
several studies, adolescents themselves indicate that their
choices are influenced by this proximity.67,71
Adolescent autonomy, agency, and the modern food
environment together create circumstances that promote
unhealthy diets
Autonomy, common for most adolescents in most
modern food environments, offers opportunities to
express agency, but also facilitates a strong influence of
peers, advertising, and promotion on food choices.
Modern food environments have high levels of food
advertising and promotion targeting adolescents,72,73
and
research has shown that exposure to advertising of
nutrient-poor, energy-dense foods is linked to their
preference.74–77
Adolescents are exposed to food marketing
through many avenues, including television, movies,
videos, advergames, product placements, crosspromotions,
product packaging, athlete and celebrity
sponsorships, philanthropic food and beverage company
donations, billboards, and social media.72,73,78,79
The
literature reveals evidence of socioeconomic targeting of
youth-focused marketing of nutrient-poor, energy-dense
foods, for example in Spain,68
the UK,65
and the USA.80
The many diverse forms of social media81,82
appeal to
adolescents’ growing desire for autonomy, social
interaction, and identity exploration,78
with both positive
(eg, social connection), and negative (eg, cyberbullying)
consequences.83–85
For many adolescents, social media
platforms provide parent-free zones for exploration.86
Almost all (90%) of 16–24 year olds in the Organisation
for Economic Co-operation and Development countries
use social networks.87
Use in LMICs is rapidly rising,88
but is variable across socioeconomic groups and
countries, with high usage in the Middle East and Latin
America.88
In our pooled analysis, social media use was
ubiquitous in the modern food environment site, and
essentially absent in traditional food environments.
Social media has created new youth-targeted
advertising opportunities that go well beyond traditional
media. Food companies pay for advertisements
embedded in social media feeds that often include highly
engaging and interactive content89
and maintain free
accounts that users can “friend” or “follow,” blurring the
lines between advertising, entertainment, and social
interaction.78,90
Unprecedented data capture on youth
engagement with brands is used to refine advertising
techniques.78
These techniques, and social media
influencers (online personalities often paid to promote
brands, including youth influencers on YouTube91
)
expose adolescents to marketing in covert ways.92–94
One study suggests youth were more likely to like and
share posts illustrating and promoting unhealthy foods
than those promoting healthy foods.95
However, a
2021 study identified vegan, homemade, clean, and plantbased
as the words most commonly used to identify
healthy food using data extracted from more than
Series
www.thelancet.com Vol 399 January 8, 2022	 193
2 million posts from 427 936 unique users of a social
media platform.96
Vegan and vegetarian diets can put
adolescents at higher risk of deficiency of several
nutrients, if not carefully planned and monitored.97
Social
media and other forms of media could be leveraged to
provide information needed to promote healthy eating
generally, and nutritional adequacy for those who choose
specific dietary patterns. Although examples are still few,
the potential to promote healthy dietary patterns through
social media is promising.98
However, social media
companies are self-regulated, and although some have
made commitments to restrict advertising of alcohol,
tobacco, or gambling, none restrict promotion of
nutrient-poor, energy-dense food, and commitments to
promote healthy foods and dietary patterns are lacking.99
Adolescents also directly influence each other via social
media. Peer norms and judgment can be expressed
quickly in quantifiable ways such as “likes,”100
exploiting
adolescents’ heightened social sensitivity.101
Social media
also creates increased opportunities to compare one’s
own image to that of friends and celebrities, posing
major risks for negative body image and eating
concerns.102,103
Cyberbullying is another worry.102
Data
from the USA, Iceland, Canada, and Australia show that
weight is the number one perceived reason adolescents
are bullied,104,105
and evidence suggests a link between
weight-based and appearance-based teasing and
disordered eating.106,107
Nevertheless, social media also
offers opportunities for positive influences. For example,
although, to our knowledge, it has not been evaluated for
impact on eating and food choice, the body positivity
movement on social media could help to mitigate the
negative effects of weight and appearance pressures on
self-esteem.108
Social media can also be a platform to
deliver positive messages, guidance, training, and peer
support;109,110
help with disease surveillance; and enhance
health professionals’ ability to influence policy making.110
Implications for policy and programmes in modern food
environment contexts
Given their autonomy and agency, there is great potential
for adolescents to be active drivers of change in favour of
better diets in modern food environments. However,
efforts must be accompanied by strong regulation and its
enforcement—including, but not limited to, foods sold
in and around schools.111,112
Regulation to restrict
advertising and promotion of unhealthy foods on social
media is urgently needed.110
Further safeguards are
needed among socioeconomically disadvantaged
populations, among whom food insecurity persists even
in modern food environments,113
and for whom there is
evidence of greater targeted unhealthy food marketing.90,114
However, such social safety nets must be carefully
designed to promote healthy eating and avoid increasing
overweight and related health risks, as has been reported,
for example, in adolescent recipients of the Supplemental
Nutrition Assistance Program in the USA.115
Conclusions
Dietary intake during adolescence sets the foundation for
a healthy life, but adolescents are highly diverse in their
dietary patterns, developmental trajectories, and in the
factors that influence food choice. Contextual factors are
central to food choice among adolescents, but even the
interpretation of choice is highly contextual, with
individual decisions inextricably linked to gendered roles
and responsibilities in traditional food environments.
Our findings reinforce the importance of food insecurity
and the profound impact of poverty on adolescents. This
situation is only being exacerbated by the COVID-19
pandemic. Early evidence suggests that more families
are being pushed into food insecurity and shifting
towards lower-cost, less nutritious non-perishable
foods.116
Even in less food-insecure contexts, social
isolation is resulting in negative trends among some
adolescents, such as reported weight gain, poor eating
habits, and stress eating (eg, in Greece,117
the USA,118
and
Italy119
).
Regardless of context, our Series paper illustrates that
adolescents are not just older children or younger
adults; they are unique, with needs, risks, and
opportunities related to dietary intake and food choice.
To be effective, policy and programme actions must
recognise the unique development trajectory, social and
cultural context, and the nuanced set of roles and
responsibilities that adolescents have in relation to food.
Recognising adolescence as a unique life stage and
designing programmes with the active input of
adolescents to foster healthy dietary patterns and food
choice is long overdue. One such approach in
Bangladesh (the Bhalo Khabo Bhalo Thakbo campaign)
has resulted in over 1 million adolescents pledging to
use their pocket money to buy more nutritious food,
and provides them with resources on how to do so
(evaluation ongoing).
Profound change to dietary intake cannot be achieved
without fundamental improvements to the food
environment, implying change across all arcs of the
conceptual framework4
of this Series. While important
evidence gaps remain, inaction is not an option.
Combinations of regulatory (eg, regulation of social
media, restrictions or bans on unhealthy foods in
schools), and programmatic action are urgently needed.
There is much room for improvement with regard to the
adoption of and compliance with existing regulations,
even in modern food environments. For example,
Vandevijvere and colleagues114
found that about 65% of
foods advertised around schools in New Zealand did not
comply with corresponding WHO criteria. Leveraging
ongoing positive youth-generated social movements,
such as climate change,120
could help generate the muchneeded
sense of urgency regarding the current state of
food environments. Interestingly, societal motives for
food choice, such as the environment, were not
mentioned in any of our pooled analysis sites. The
For Bhalo Khabo BhaloThakbo
see https://www.
bhalokhabobhalothakbo.com/
Series
194	 www.thelancet.com Vol 399 January 8, 2022
environment or animal welfare concerns have been
mentioned among motives for reducing animal-source
food consumption or becoming vegetarian in Germany,121
the USA,122
Brazil,123
Australia,124
and New Zealand125
(as
examples, and reviewed by Sanchez-Sabate and
colleagues121
). Global efforts to transform food systems,
such as the 2021 UN Food Systems Summit, and
positioning healthy, sustainable diets as a right for
children and adolescents126
within such efforts could help
build momentum in this regard; youth are actively
engaged to make this happen.127
Contributors
LMN wrote the paper with substantial contributions from MB, PH-J, SS,
SW (performed analysis and wrote the draft of the pooled qualitative
analysis, and led Supplementary Annex 2); ABS (wrote the draft of the
adolescent development section); CAR (wrote the draft of the literature
review for modern food environments and shared in initial
conceptualisation of the manuscript); AT (wrote the draft of the literature
review for traditional and mixed food environments); TB (led
Supplementary Annex 1); TB, AL, SR-R, TS-L, VS, ZZ (performed data
analysis, prepared figures, and wrote the draft for the three-country case
study of dietary intake); and KMD (led the systematic review of dietary
evidence availability and prepared the map of results). All authors
provided comments and suggestions to multiple versions of the
manuscript and read and approved the final version. LMN holds final
responsibility for its content.
Declaration of interests
MB reports grants from the UK Medical Research Council and grants
from the UK National Institute for Health Research (NIHR), during
the conduct of the study. All other authors declare no competing
interests.
Acknowledgments
This work received funding support from Fondation Botnar and the
Wellcome Trust. Neither organisation played any role in writing the
manuscript or the decision to submit for publication. We gratefully
acknowledge support from Mona Ghadirian, Heather Kelahan, and
Jamie Marquis to the systematic review of dietary intake evidence. The
data for the India case study were analysed from the Comprehensive
National Nutrition Survey (CNNS) 2016–18, conducted under the
leadership of the Ministry of Health and Family Welfare (MoHFW),
Government of India, and Technical Advisory Committee designated
by the MoHFW, in collaboration with UNICEF and the Population
Council. The CNNS (a previous survey from which we extracted data
for the India case study) was funded through a generous grant from
the Aditya and Megha Mittal Foundation. The China National
Nutrition Survey was supported by the National Natural Science
Foundation of China (82073573). Mexico’s National Survey of Health
and Nutrition was funded by the Secretary of Health of Mexico
through a grant to the National Institutes of Public Health, Mexico.
We are grateful to the collaborators of the TALENT consortium for
making their data available (details of the consortium in appendix).
EACH-B is funded by the UK NIHR Programme Grants for Applied
Research (RP-PG-0216-20004). The views expressed in this publication
are those of the authors and not necessarily those of the NIHR or the
Department of Health and Social Care. VS and AL note that the
statements in this publication are the views of the authors and do not
necessarily reflect the policies or views of UNICEF.
Editorial note: the Lancet Group takes a neutral position with respect to
territorial claims in published maps and institutional affiliations.
References
1	 Norris SA, Frongillo EA, Black MM, et al. Nutrition in adolescent
growth and development. Lancet 2021; published online Nov 29.
https://doi.org/10.1016/S0140-6736(21)01590-7.
2	 Clark H, Coll-Seck AM, Banerjee A, et al. A future for the world’s
children? A WHO-UNICEF-Lancet Commission. Lancet 2020;
395: 605–58.
For the UN Food Systems
Summit see https://www.un.
org/en/food-systems-summit
3	 Patton GC, Sawyer SM, Santelli JS, et al. Our future: a Lancet
commission on adolescent health and wellbeing. Lancet 2016;
387: 2423–78.
4	 Hargreaves D, Mates E, Menon P, et al. Strategies and interventions
for healthy adolescent growth, nutrition, and development. Lancet
2021; published online Nov 29. https://doi.org/10.1016/S0140-
6736(21)01593-2.
5	 UNICEF, GAIN. Food systems for children and adolescents:
working together to secure nutritious diets. Report of a global
consultation co-hosted by UNICEF and GAIN. Florence: UNICEF,
2018.
6	 Turner C, Aggarwal A, Walls H, et al. Concepts and critical
perspectives for food environment research: a global framework
with implications for action in low- and middle-income countries.
Glob Food Secur 2018; 18: 93–101.
7	 Downs SM, Ahmed S, Fanzo J, Herforth A. Food environment
typology: advancing an expanded definition, framework, and
methodological approach for improved characterization of wild,
cultivated, and built food environments toward sustainable diets.
Foods 2020; 9: 532.
8	 HLPE. Nutrition and food Systems. A report by the High-Level
Panel of Experts on Food Security and Nutrition of the Committee
on World Food Security. Rome: Food and Agriculture Organization
of the United Nations, 2017.
9	 Herforth A, Ahmed S. The food environment, its effects on dietary
consumption, and potential for measurement within agriculturenutrition
interventions. Food Secur 2015; 7: 505–20.
10	 Tabacchi G, Garbagnati F, Wijnhoven TMA, et al. Dietary
assessment methods in surveillance systems targeted to
adolescents: a review of the literature. Nutr Metab Cardiovasc Dis
2019; 29: 761–74.
11	 Keats EC, Rappaport AI, Shah S, Oh C, Jain R, Bhutta ZA. The dietary
intake and practices of adolescent girls in low- and middle-income
countries: a systematic review. Nutrients 2018; 10: 1978.
12	 Ministry of Health and Family Welfare (MoHFW), Government of
India, UNICEF, Population Council. Comprehensive National
Nutrition Survey 2016–2018. New Delhi, 2019.
13	 Beal T, Morris SS, Tumilowicz A. Global patterns of adolescent
fruit, vegetable, carbonated soft drink, and fast-food consumption:
a meta-analysis of Global School-based Student Health Surveys.
Food Nutr Bull 2019; 40: 444–59.
14	 WHO. Fruit and vegetables for health: report of a Joint FAO/WHO
Workshop, 1–3 September 2004, Kobe, Japan. World Health
Organization, 2004.
15	 Story M, Neumark-Sztainer D, French S. Individual and
environmental influences on adolescent eating behaviors.
J Am Diet Assoc 2002; 102 (suppl): S40–51.
16	 Story M, Kaphingst KM, Robinson-O’Brien R, Glanz K. Creating
healthy food and eating environments: policy and environmental
approaches. Annu Rev Public Health 2008; 29: 253–72.
17	 Pfeifer JH, Berkman ET. The development of self and identity in
adolescence: neural evidence and implications for a value-based
choice perspective on motivated behavior. Child Dev Perspect 2018;
12: 158–64.
18	 Chandra-Mouli V, Plesons M, Adebayo E, et al. Implications of the
global early adolescent study’s formative research findings for
action and for research. J Adolesc Health 2017; 61 (suppl): S5–9.
19	 Dahl RE, Allen NB, Wilbrecht L, Suleiman AB. Importance of
investing in adolescence from a developmental science perspective.
Nature 2018; 554: 441–50.
20	 Crockett LJ, Crouter AC. Pathways through adolescence: Individual
development in relation to social contexts. Hillsdale, NJ:
Lawrence Erlbaum Associates, 1995.
21	 Schlegel A, Barry H 3rd. Adolescence: an anthropological inquiry.
New York, NY: Free Press, 1991.
22 	 Hadley DC, Lindstrom D, Tessema F, Belachew T. Gender bias in
the food insecurity experience of Ethiopian adolescents. Soc Sci Med
1982 2008; 66: 427.
23	 Aurino E. Do boys eat better than girls in India? Longitudinal
evidence on dietary diversity and food consumption disparities
among children and adolescents. Econ Hum Biol 2017; 25: 99–111.
24	 Falconi A, Gemmill A, Dahl RE, Catalano R. Adolescent experience
predicts longevity: evidence from historical epidemiology.
J Dev Orig Health Dis 2014; 5: 171–77.
Series
www.thelancet.com Vol 399 January 8, 2022	 195
25	 Depauw E, Oxley D. Toddlers, teenagers, and terminal heights: the
importance of puberty for male adult stature, Flanders, 1800–76.
Econ Hist Rev 2019; 72: 925–52.
26	 Peper JS, Koolschijn PCMP, Crone EA. Development of risk taking:
contributions from adolescent testosterone and the orbito-frontal
cortex. J Cogn Neurosci 2013; 25: 2141–50.
27	 Cardoos SL, Ballonoff Suleiman A, Johnson M, van den Bos W,
Hinshaw SP, Dahl RE. Social status strategy in early adolescent
girls: testosterone and value-based decision making.
Psychoneuroendocrinology 2017; 81: 14–21.
28	 Galván A. The teenage brain: sensitivity to rewards.
Curr Dir Psychol Sci 2013; 22: 88–93.
29	 Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause
excess calorie intake and weight gain: an inpatient randomized
controlled trial of ad libitum food intake. Cell Metab 2019; 30: 226.
30	 Tremblay L, Lariviere M. The influence of puberty onset, body mass
index, and pressure to be thin on disordered eating behaviors in
children and adolescents. Eat Behav 2009; 10: 75–83.
31	 Contento IR, Williams SS, Michela JL, Franklin AB. Understanding
the food choice process of adolescents in the context of family and
friends. J Adolesc Health 2006; 38: 575–82.
32	 McElhaney KB, Allen JP, Stephenson JC, Hare AL. Attachment and
autonomy during adolescence. In: Lerner RM, Steinberg L, eds.
Handbook of adolescent psychology. Hoboken, NJ: John Wiley &
Sons, 2009: 358–403.
33	 Dahl RE. Adolescent brain development: a period of vulnerabilities
and opportunities. Keynote address. Ann N Y Acad Sci 2004;
1021: 1–22.
34	 Raman S, Srinivasan K, Kurpad A, Ritchie J, Razee H. “We have to
ask and only then do”: unpacking agency and autonomy in women’s
reproductive health in urban India. Health Care Women Int 2016;
37: 1119–37.
35	 Herr RS. Agency without autonomy: valuational agency.
J Glob Ethics 2010; 6: 239–54.
36	 Anderson J. Autonomy, agency and the self. In: Fultner B, ed.
Jürgen Habermas: key concepts. Durham: Acumen Publishing,
2011: 91–112.
37	 Barker ME, Hardy-Johnson P, Weller S, et al. How do we improve
adolescent diet and physical activity in India and sub-Saharan
Africa? Findings from the Transforming Adolescent Lives through
Nutrition (TALENT) consortium. Public Health Nutr 2020;
24: 5309–17.
38	 Weller S, Hardy-Johnson P, Strommer S, et al. ‘I should be disease
free, healthy and be happy in whatever I do’: a cross-country
analysis of drivers of adolescent diet and physical activity in
different low- and middle-income contexts. Public Health Nutr 2020;
24: 5238–48.
39	 Blum LS, Mellisa A, Kurnia Sari E, et al. In-depth assessment of
snacking behaviour in unmarried adolescent girls 16-19 years of age
living in urban centres of Java, Indonesia. Matern Child Nutr 2019;
15: e12833.
40	 Blum LS, Khan R, Sultana M, et al. Using a gender lens to
understand eating behaviours of adolescent females living in
low-income households in Bangladesh. Matern Child Nutr 2019;
15: e12841.
41	 Davidson E, Edwards R, Jamieson L, Weller S. Big data, qualitative
style: a breadth-and-depth method for working with large
amounts of secondary qualitative data. Qual Quant 2019;
53: 363–76.
42	 Hall BJ, Garabiles MR, de Hoop J, Pereira A, Prencipe L,
Palermo TM. Perspectives of adolescent and young adults on
poverty-related stressors: a qualitative study in Ghana, Malawi and
Tanzania. BMJ Open 2019; 9: e027047.
43	 World Food Programme. Formative research to inform adolescent
programming in Kenya. Rome: World Food Programme, 2018.
44	 World Food Programme. Formative research to inform adolescent
programming in Uganda. Rome: World Food Programme, 2019.
45	 Morrow V, Tafere Y, Chuta N, Zharkevich I. “I started working
because I was hungry”: the consequences of food insecurity for
children’s well-being in rural Ethiopia. Soc Sci Med 2017; 182: 1–9.
46	 Lee J, Pelto GH, Habicht J-P, Bhuiyan MMI, S Jalal C. Identifying
nutrition and health-relevant behaviors, beliefs, and values of
school-going adolescent girls in rural Bangladesh: context for
interventions. Curr Dev Nutr 2019; 3: nzz013.
47	 Kurschner S, Madrigal L, Chacon V, Barnoya J, Rohloff P. Impact of
school and work status on diet and physical activity in rural
Guatemalan adolescent girls: a qualitative study. Ann N Y Acad Sci
2020; 1468: 16–24.
48	 El-Ammari A, El Kazdouh H, Bouftini S, El Fakir S, El Achhab Y.
Social-ecological influences on unhealthy dietary behaviours among
Moroccan adolescents: a mixed-methods study. Public Health Nutr
2020; 23: 996–1008.
49	 Stigler MH, Arora M, Dhavan P, Shrivastav R, Reddy KS, Perry CL.
Weight-related concerns and weight-control behaviors among
overweight adolescents in Delhi, India: a cross-sectional study.
Int J Behav Nutr Phys Act 2011; 8: 9.
50	 Askari Majabadi H, Solhi M, Montazeri A, et al. Factors influencing
fast-food consumption among adolescents in Tehran: a qualitative
study. Iran Red Crescent Med J 2016; 18: e23890.
51	 Brown C, Shaibu S, Maruapula S, Malete L, Compher C.
Perceptions and attitudes towards food choice in adolescents in
Gaborone, Botswana. Appetite 2015; 95: 29–35.
52	 Kabir A, Miah S, Islam A. Factors influencing eating behavior and
dietary intake among resident students in a public university in
Bangladesh: a qualitative study. PLoS One 2018; 13: e0198801.
53	 Banna JC, Buchthal OV, Delormier T, Creed-Kanashiro HM,
Penny ME. Influences on eating: a qualitative study of
adolescents in a periurban area in Lima, Peru. BMC Public Health
2016; 16: 40.
54	 Swaminathan S, Thomas T, Kurpad AV, Vaz M. Perceptions of
healthy eating: a qualitative study of school-going children in South
India. Health Educ J 2009; 68: 94–110.
55	 Vijayapushpam T, Menon KK, Raghunatha Rao D, Maria Antony G.
A qualitative assessment of nutrition knowledge levels and dietary
intake of schoolchildren in Hyderabad. Public Health Nutr 2003;
6: 683–88.
56	 Weaver LJ, Tadess Y, Stevenson EGJ, Hadley C. “I want variety!”:
dietary variety as aesthetic pursuit, social signal, and nutritional
vehicle in Brazil and Ethiopia. Hum Organ 2019; 78: 122–32.
57	 Maxfield A, Patil S, Cunningham SA. Globalization and food
prestige among Indian adolescents. Ecol Food Nutr 2016;
55: 341–64.
58	 Harrell M, Medina J, Greene-Cramer B, Sharma SV, Arora M,
Nazar G. Understanding eating behaviors of New Dehli’s youth.
J Appl Res Child 2015; 6: 18.
59	 Berger J. Identity signaling, social influence, and social contagion.
In: Prinstein M, Dodge K, eds. Understanding peer influence in
children and adolescents. New York, NY: The Guilford Press,
2008: 181–99.
60	 Noll PRES, Noll M, de Abreu LC, Baracat EC, Silveira EA,
Sorpreso ICE. Ultra-processed food consumption by Brazilian
adolescents in cafeterias and school meals. Sci Rep 2019; 9: 7162.
61	 Laska MN, Hearst MO, Forsyth A, Pasch KE, Lytle L.
Neighbourhood food environments: are they associated with
adolescent dietary intake, food purchases and weight status?
Public Health Nutr 2010; 13: 1757–63.
62	 Hearst MO, Pasch KE, Laska MN. Urban v. suburban perceptions of
the neighbourhood food environment as correlates of adolescent
food purchasing. Public Health Nutr 2012; 15: 299–306.
63	 Sadler RC, Clark AF, Wilk P, O’Connor C, Gilliland JA. Using GPS
and activity tracking to reveal the influence of adolescents’ food
environment exposure on junk food purchasing. Can J Public Health
2016; 107 (suppl 1): 5346.
64	 Kelly C, Callaghan M, Molcho M, Nic Gabhainn S,
Alforque Thomas A. Food environments in and around postprimary
schools in Ireland: associations with youth dietary habits.
Appetite 2019; 132: 182–89.
65	 Wills W, Danesi G, Kapetanaki AB, Hamilton L. Socio-economic
factors, the food environment and lunchtime food purchasing by
young people at secondary school. Int J Environ Res Public Health
2019; 16: 1605.
66	 Palla L, Chapman A, Beh E, Pot G, Almiron-Roig E. Where do
adolescents eat less-healthy foods? Correspondence analysis and
logistic regression results from the UK National Diet and Nutrition
Survey. Nutrients 2020; 12: 2235.
67 	 Ronto R, Carins J, Ball L, Pendergast D, Harris N. Adolescents’
views on high school food environments. Health Promot J Austr
2020; 32: 458–66.
Series
196	 www.thelancet.com Vol 399 January 8, 2022
68	 Díez J, Cebrecos A, Rapela A, Borrell LN, Bilal U, Franco M.
Socioeconomic inequalities in the retail food environment around
schools in a southern European context. Nutrients 2019; 11: 1511.
69	 Gebremariam MK, Andersen LF, Bjelland M, et al. Does the school
food environment influence the dietary behaviours of Norwegian
11-year-olds? The HEIA study. Scand J Public Health 2012;
40: 491–97.
70	 Green MA, Radley D, Lomax N, Morris MA, Griffiths C.
Is adolescent body mass index and waist circumference associated
with the food environments surrounding schools and homes?
A longitudinal analysis. BMC Public Health 2018; 18: 482.
71	 Gangemi K, Dupuis R, FitzGerald E, Frasso R, Solomon S,
Cannuscio CC. Youth speak out on school food environments.
J Sch Nurs 2020; 36: 193–202.
72	 Harris JL, Pomeranz JL, Lobstein T, Brownell KD. A crisis in the
marketplace: how food marketing contributes to childhood obesity
and what can be done. Annu Rev Public Health 2009; 30: 211–25.
73	 Powell LM, Harris JL, Fox T. Food marketing expenditures aimed at
youth: putting the numbers in context. Am J Prev Med 2013;
45: 453–61.
74	 Sadeghirad B, Duhaney T, Motaghipisheh S, Campbell NRC,
Johnston BC. Influence of unhealthy food and beverage marketing
on children’s dietary intake and preference: a systematic review and
meta-analysis of randomized trials. Obes Rev 2016; 17: 945–59.
75	 Harris JL, Bargh JA, Brownell KD. Priming effects of television food
advertising on eating behavior. Health Psychol 2009; 28: 404–13.
76	 McClure AC, Tanski SE, Gilbert-Diamond D, et al. Receptivity to
television fast-food restaurant marketing and obesity among U.S.
youth. Am J Prev Med 2013; 45: 560–68.
77	 Scully M, Wakefield M, Niven P, et al. Association between food
marketing exposure and adolescents’ food choices and eating
behaviors. Appetite 2012; 58: 1–5.
78	 Montgomery KC, Chester J, Grier SA, Dorfman L. The new threat
of digital marketing. Pediatr Clin North Am 2012; 59: 659–75, viii.
79	 Bragg MA, Roberto CA, Harris JL, Brownell KD, Elbel B. Marketing
food and beverages to youth through sports. J Adolesc Health 2018;
62: 5–13.
80	 Allcott H, Diamond R, Dubé J-P, Handbury J, Rahkovsky I,
Schnell M. Food deserts and the causes of nutritional inequality.
Q J Econ 2019; 134: 1793–844.
81	 Capurro D, Cole K, Echavarría MI, Joe J, Neogi T, Turner AM.
The use of social networking sites for public health practice and
research: a systematic review. J Med Internet Res 2014; 16: e79.
82	 Hagg E, Dahinten VS, Currie LM. The emerging use of social
media for health-related purposes in low and middle-income
countries: a scoping review. Int J Med Inform 2018; 115: 92–105.
83	 Aboujaoude E, Savage MW, Starcevic V, Salame WO. Cyberbullying:
review of an old problem gone viral. J Adolesc Health 2015;
57: 10–18.
84	 O’Keeffe GS, Clarke-Pearson K. The impact of social media on
children, adolescents, and families. Pediatrics 2011; 127: 800–04.
85	 Starcevic V, Aboujaoude E. Cyberchondria, cyberbullying,
cybersuicide, cybersex: “new” psychopathologies for the
21st century? World Psychiatry 2015; 14: 97–100.
86	 Anderson L, McCabe DB. A co-constructed world: adolescent selfsocialization
on the internet. J Public Policy Mark 2012; 31: 240–53.
87	 Ortiz-Ospina E. The rise of social media. Our World in Data.
Sept 18, 2019. https://ourworldindata.org/rise-of-social-media
(accessed July 30, 2020).
88 	 Poushter J, Bishop C, Chwe H. Social media use continues to rise
in developing countries, but plateaus across developed ones.
Washington, DC: Pew Research Center, 2018.
89	 Freeman B, Kelly B, Baur L, et al. Digital junk: food and beverage
marketing on Facebook. Am J Public Health 2014; 104: e56–64.
90	 Fleming-Milici F, Harris JL. Adolescents’ engagement with
unhealthy food and beverage brands on social media. Appetite 2020;
146: 104501.
91	 Alruwaily A, Mangold C, Greene T, et al. Child social media
influencers and unhealthy food product placement. Pediatrics 2020;
146: e20194057.
92	 Lou C, Yuan S. Influencer marketing: how message value and
credibility affect consumer trust of branded content on social
media. J Interact Advert 2019; 19: 58–73.
93	 Qutteina Y, De Backer C, Smits T. Media food marketing and eating
outcomes among pre-adolescents and adolescents: a systematic
review and meta-analysis. Obes Rev 2019; 20: 1708–19.
94	 Smit CR, Buijs L, van Woudenberg TJ, Bevelander KE, Buijzen M.
The impact of social media influencers on children’s dietary
behaviors. Front Psychol 2020; 10: 2975.
95	 Murphy G, Corcoran C, Tatlow-Golden M, Boyland E, Rooney B.
See, like, share, remember: adolescents’ responses to unhealthy-,
healthy- and non-food advertising in social media.
Int J Environ Res Public Health 2020; 17: 2181.
96	 Pilař L, Stanislavská LK, Kvasnička R, Hartman R, Tichá I. Healthy
food on Instagram social network: vegan, homemade and clean
eating. Nutrients 2021; 13: 1991.
97	 Rudloff S, Bührer C, Jochum F, et al. Vegetarian diets in childhood
and adolescence: position paper of the nutrition committee,
German Society for Paediatric and Adolescent Medicine (DGKJ).
Mol Cell Pediatr 2019; 6: 4.
98	 Folkvord F, Hermans RCJ. Food marketing in an obesogenic
environment: a narrative overview of the potential of healthy food
promotion to children and adults. Curr Addict Rep 2020; 7: 431–36.
99	 Sacks G, Looi ESY. The advertising policies of major social media
platforms overlook the imperative to restrict the exposure of
children and adolescents to the promotion of unhealthy foods and
beverages. Int J Environ Res Public Health 2020; 17: 4172.
100	 Sherman LE, Greenfield PM, Hernandez LM, Dapretto M.
Peer influence via Instagram: effects on brain and behavior in
adolescence and young adulthood. Child Dev 2018; 89: 37–47.
101	 Somerville LH. Special issue on the teenage brain: sensitivity to
social evaluation. Curr Dir Psychol Sci 2013; 22: 121–27.
102	 Richards D, Caldwell PH, Go H. Impact of social media on the
health of children and young people. J Paediatr Child Health 2015;
51: 1152–57.
103	 Tiggemann M, Slater A. NetGirls: the Internet, Facebook, and body
image concern in adolescent girls. Int J Eat Disord 2013;
46: 630–33.
104	 Puhl RM, Luedicke J, Heuer C. Weight-based victimization toward
overweight adolescents: observations and reactions of peers.
J Sch Health 2011; 81: 696–703.
105	 Puhl RM, Latner JD, O’Brien K, Luedicke J, Forhan M,
Danielsdottir S. Cross-national perspectives about weight-based
bullying in youth: nature, extent and remedies. Pediatr Obes 2016;
11: 241–50.
106	 Haines J, Neumark-Sztainer D, Eisenberg ME, Hannan PJ. Weight
teasing and disordered eating behaviors in adolescents: longitudinal
findings from Project EAT (Eating Among Teens). Pediatrics 2006;
117: e209–15.
107	 Menzel JE, Schaefer LM, Burke NL, Mayhew LL, Brannick MT,
Thompson JK. Appearance-related teasing, body dissatisfaction,
and disordered eating: a meta-analysis. Body Image 2010;
7: 261–70.
108	 Davies B, Turner M, Udell J. Add a comment … how fitspiration and
body positive captions attached to social media images influence
the mood and body esteem of young female Instagram users.
Body Image 2020; 33: 101–05.
109	 Korda H, Itani Z. Harnessing social media for health promotion
and behavior change. Health Promot Pract 2013; 14: 15–23.
110	 Islam SMS, Tabassum R, Liu Y, et al. The role of social media in
preventing and managing non-communicable diseases in
low-and-middle income countries: hope or hype?
Health Policy Technol 2019; 8: 96–101.
111	 Kenney EL, Barrett JL, Bleich SN, Ward ZJ, Cradock AL, Gortmaker
SL. Impact of the healthy, hunger-free kids act on obesity trends.
Health Aff (Millwood) 2020; 39: 1122–29.
112	 Andretti B, Goldszmidt RB, Andrade EB. How changes in menu
quality associate with subsequent expenditure on (un)healthy foods
and beverages in school cafeterias: a three-year longitudinal study.
Prev Med 2021; 146: 106456.
113	 Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household
food security in the United States in 2019, ERR-275. US Department
of Agriculture, Economic Research Service, 2020.
114	 Vandevijvere S, Molloy J, Hassen de Medeiros N, Swinburn B.
Unhealthy food marketing around New Zealand schools: a national
study. Int J Public Health 2018; 63: 1099–107.
Series
www.thelancet.com Vol 399 January 8, 2022	 197
115	 Lee AM, Scharf RJ, Filipp SL, Gurka MJ, DeBoer MD.
Food insecurity is associated with prediabetes risk among U.S.
adolescents, NHANES 2003–2014. Metab Syndr Relat Disord 2019;
17: 347–54.
116	 Adams EL, Caccavale LJ, Smith D, Bean MK. Food insecurity,
the home food environment, and parent feeding practices in the era
of COVID-19. Obesity (Silver Spring) 2020; 28: 2056–63.
117	 Androutsos O, Perperidi M, Georgiou C, Chouliaras G. Lifestyle
changes and determinants of children’s and adolescents’ body
weight increase during the first COVID-19 lockdown in Greece:
the COV-EAT study. Nutrients 2021; 13: 930.
118	 Powell PK, Lawler S, Durham J, Cullerton K. The food choices of
US university students during COVID-19. Appetite 2021; 161: 105130.
119	 Orben A, Tomova L, Blakemore S-J. The effects of social deprivation
on adolescent development and mental health.
Lancet Child Adolesc Health 2020; 4: 634–40.
120	 Boulianne S, Lalancette M, Ilkiw D. “School Strike 4 Climate”:
social media and the international youth protest on climate change.
Media Commun 2020; 8: 208–18.
121	 Sanchez-Sabate R, Sabaté J. Consumer attitudes towards
environmental concerns of meat consumption: a systematic review.
Int J Environ Res Public Health 2019; 16: 1220.
122	 Neff RA, Edwards D, Palmer A, Ramsing R, Righter A, Wolfson J.
Reducing meat consumption in the USA: a nationally
representative survey of attitudes and behaviours.
Public Health Nutr 2018; 21: 1835–44.
123	 Hargreaves SM, Nakano EY, Zandonadi RP. Brazilian vegetarian
population—influence of type of diet, motivation and
sociodemographic variables on quality of life measured by specific
tool (VEGQOL). Nutrients 2020; 12: 1406.
124	 Trethewey E, Jackson M. Values and cognitive mechanisms:
comparing the predictive factors of Australian meat intake. Appetite
2019; 142: 104386.
125	 Kemper JA, White SK. Young adults’ experiences with
flexitarianism: the 4Cs. Appetite 2021; 160: 105073.
126	 EAT, UNICEF. Diets of children and adolescents: unlocking current
and future gains for human and planetary health. 2020.
127	 UN Food Systems Summit. Youth movement leads the charge
worldwide for food systems transformation ahead of UN summit.
https://www.un.org/en/food-systems-summit/press/youth-
movement-leads-charge-worldwide-food-systems-transformationahead-un
(accessed April 10, 2021).
Copyright © 2021 Elsevier Ltd. All rights reserved.