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Dietary Assessment

When assessing an adolescent’s diet, it is important to ask specific questions. There are several dietary assessment strategies, among which the 24 h recall is the commonly used clinically. The 24 h recall involves asking the teenager very specifically about what they ate and drank over the past day including portion sizes. Depending on the population, it might be worthwhile to provide a food frequency questionnaire where the teen can check off how many times per week they eat vegetables and how often they drink soda, for example. Some adolescents might have an easier time remembering what they ate if they are asked to take a photo of each meal or log the meal into an online tracker. The best dietary assessment strategy to use will depend on the adolescent’s nutritional goals. For example, you would not necessarily want a teenager struggling with an eating disorder to track their intake using a website that listed calories.

Energy Requirements

Energy requirements for teenagers can vary greatly depending on their physical activity level (PAL) and current stage of growth. The Institute of Medicine (IOM) published estimated energy requirements (EERs) based on a global doubly labeled water database. The EER for adolescents 9–18 years of age includes the total energy expenditure, in addition to calories needed for energy deposition. For boys, EER is calculated as follows:

EER . 88:5  .61:9  age .y.+ PA

x 26:7  + weight .kg + 903 x height .m. + 25 kcal

where PA is the physical activity coefficient:

PA.1.00 if PAL is estimated to be1.0<1.4 (sedentary).

PA.1.13 if PAL is estimated to be1.4<1.6 (low active).

PA.1.26 if PAL is estimated to be1.6<1.9 (active).

PA.1.42 if PAL is estimated to be1.9<2.5 (very active).

For girls aged 9–18 years, EER is calculated as follows:

EER = 135:3  – 30:8 x age + PA

x 10:0  x weight .kg + 934  x height .m. + 25 kcal

where PA is the physical activity coefficient:

PA.1.00 if PAL is estimated to be1.0<1.4 (sedentary).

PA.1.16 if PAL is estimated to be1.4<1.6 (low active).

PA.1.31 if PAL is estimated to be1.6<1.9 (active).

PA.1.56 if PAL is estimated to be1.9<2.5 (very active).

 Dietary Guidelines

Various agencies and organizations around the world have published standards and guidelines for what constitutes an  adolescent boys aged 9–13 is 34 g per day and for adolescent boys aged 14–18 is 52 g per day. The RDA is 34 g per day for girls aged 9–13 and 46 g per day for girls aged 14–18. Protein is found in animal products such as meat, poultry, fish, dairy, and eggs and in beans, legumes, and nuts.

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Fat

It is necessary for the diet to contain fat in order to help absorb fat-soluble vitamins (vitamins A, D, E, and K) and to provide linoleic acid and linolenic acid, essential for neurological

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development and growth. The acceptable macronutrient distribution range for fat for teenagers of both genders is 25–35 g per day. Adolescents should attempt to eat as little trans fat as possible and limit the amount of saturated fat in their diet. Sources of fat in the diet include dairy, cheese, butter, oil, avocado, certain fish, certain cuts of meat, and nuts.

Vitamins and Minerals

Certain vitamins and minerals have a recommended dietary allowance (RDA), while others have only an established AI because no RDA has been established. See Table 2 for a list of select vitamins and minerals and the suggested intake levels for adolescents. Most of these nutrients can be consumed in these suggested amounts by eating a balanced, varied diet that includes fruit and vegetables. In the absence of adequate portions of these healthy foods, however, a multivitamin or other supplement may be warranted. One particular nutrient of special importance during adolescence is calcium, which is aided in absorption by vitamin D. Adequate calcium intake during adolescence is key for preventing osteoporosis because childhood and adolescence are the time when bones are gaining strength and density that cannot be made up for later in life. Calcium can be found in the diet in beverages such as milk and soy milk and in foods such as tofu, beans, yogurt, cheese, almonds, canned seafood, leafy green vegetables, and fortified foods such as cereal and snack bars.

Hydration

The Holliday–Segar method of figuring hydration needs is used in hospitals but can also be applied to healthy adolescence. The equation is as follows:

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The daily recommended intake (DRI) can also be used to determine the recommended fluid intake for teenagers. For males aged 9–13 years, the DRI is 2.4 l per day; for males aged 14–18, it is 3.3 l per day. For females aged 9–13, the DRI is 2.1 l per day; for females aged 14–18, it is 2.3 l per day. This includes all liquids consumed such as water and other beverages, in addition to liquids and moisture in foods such as soup, watermelon, and cucumber.

 Supplements and Alcohol

Energy Drinks

Energy drinks such as Red Bull, 5-Hour ENERGY, and Monster Energy drink are a growing product category that seems to appeal to adolescents. Studies have shown not only that there are potential negative health effects to the energy drinks themselves but also that those adolescents who consume energy drinks are at higher risk of substance use such as smoking, drinking alcohol, and using illicit drugs. The American Academy of Pediatrics recommends that children and adolescents avoid consuming energy drinks, suggesting that they use water as their primary source of hydration.

Alcohol

According to a recent YRBSS report, 66.2% of high school students reported having had at least one alcoholic drink in their life. During the 30 days prior to the survey, 34.9% of teenagers had consumed alcohol at least once and 20.8% had had five or more drinks in one sitting, the definition of binge drinking. Teen consumption of alcohol remains a problem for many reasons. According to the American Academy of Pediatrics, alcohol can interfere with adolescent brain development, which continues into young adulthood. In addition, using alcohol during adolescence can promote the risk of alcoholism later in life, can lead to motor vehicle-related fatalities (the leading cause of death among US teens), and can lead to other mental and physical disorders. From a nutritional perspective, alcohol provides excess calories, which when consumed in large quantities can lead to overweight and obesity. Alcohol consumption is also often associated with poor dietary choices, and long-term use can affect the absorption of certain vitamins and minerals.

 Obesity

The criterion for children aged 2–20 for overweight is a BMI between the 85th and 95th percentile according to Centers for Disease Control and Prevention growth charts. For obesity, the criterion is a BMI over the 95th percentile. Obesity rates among adolescents have increased significantly over the past fourteen years. An article looking at the prevalence and trends in obesity and severe obesity showed that from 2011 to 2012, 17.4% of children aged 2–19 were obese and prevalence among adolescents exceeded 20%. Prevalence of severe obesity is also growing among youth aged 2–19 with 5.9% meeting criteria for class 2 obesity (with a BMI greater than or equal to 120% of the 95th percentile or a BMI of greater than or equal to 35) and 2.1% meeting criteria for class 3 obesity (with a BMI of greater than or equal to 140% of the 95th percentile or a BMI of greater than or equal to 40).

Sugar-Sweetened Beverages

According to YRBSS data, 27% of teenagers had consumed one nondiet soda per day 30 days leading up to the survey, and even more worrisome, 19.4% had consumed nondiet soda two or more times per day. SSBs include juice, lemonade, punch, soda, and other drinks that adolescents consume on a regular basis. These beverages (with the possible exception of juice) provide no nutritional value, but contain a large amount of calories. This is often referred to as ‘empty’ calories because they are providing nothing besides energy. Soda is often vilified when discussing causes of increased obesity in society. Indeed, the serving sizes have grown larger over the years, and the marketing does directly target young people. One recent study of SSBs on adolescents linked increased intake with greater waist circumference, a risk factor for metabolic syndrome. However, it is important to remember that while SSBs can contribute to excess calories, it is often only one piece of the obesity puzzle.

Screen Time

There is strong relationship between screen time and excess weight gain/obesity in children and adolescents. Whether this is due to the effects of commercials advertising to teens on television, the fact that one often mindlessly consumes calories when in front of a screen, the lack of physical activity due to screen time, or the effect that screen time has on sleep, experts agree that less screen time is beneficial to all children and teens, especially those at risk of overweight or obesity.

Extreme Dieting

According to the recent YRBSS data, 47.7% of teenagers reported that they were trying to lose weight with females being more likely to report this than males. Of concern, 13% of students reported that they had not eaten for twenty-four or more hours in an attempt to lose weight and 5% reported having taken diet pills. Additionally, 4.4% reported vomiting or taking laxatives to lose weight or keep from gaining weight. Extreme dieting does not work and often leads to a heavier weight in the long run. In addition, it can cause numerous health issues and nutritional deficiencies. For more information, see the section on ‘Eating Disorders.’

Type 2 Diabetes

Type 2 diabetes, also referred to as non-insulin-dependent diabetes as a way of differentiating it from type 1 diabetes (previously called juvenile diabetes), is an increasing problem among children and adolescents commonly caused by obesity. In the past, this type of diabetes was called adult-onset diabetes, but that name is no longer accurate due to the rising number of diagnoses in younger populations. In addition to obesity, several comorbidities such as proteinuria (protein in the urine), hypertension, dyslipidemia, nonalcoholic fatty liver disease, polycystic ovary syndrome (PCOS), and obstructive sleep apnea are seen among adolescent with type 2 diabetes. There are currently few treatments for type 2 diabetes in adolescents that include lifestyle changes (eating a healthy, balanced diet plus exercising regularly), pharmacology, and gastric bypass surgery.

Polycystic Ovary Syndrome

PCOS is a disease that affects 7–14% of adult women (depending on the diagnostic criteria used), with the onset happening mainly during adolescence. While no specific causes of PCOS have been definitively identified, childhood obesity is thought to be a contributing factor. PCOS is often associated with obesity, metabolic syndrome, and type 2 diabetes; it is characterized by irregular periods, hirsutism, acne, weight gain, and acanthosis nigricans. Weight loss can reduce some symptoms, but elevated insulin levels may make weight loss more difficult for adolescent girls who have PCOS compared with their healthy counterparts. Adolescent girls with PCOS can manage their insulin levels by decreasing the amount of refined carbohydrates they eat or drink, increasing the amount of protein and fiber in their diet, and getting plenty of physical activity.

 Eating Disorders

Adolescence is a particularly hard time for a person to deal with body image issues since there are so many changes happening to the body during puberty. This can set the stage for an eating disorder that may not have been an issue previously. While any disordered relationship with food can be considered an eating disorder of concern, there are differing levels of clinical severity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V), published in 2013, revised several of the previous definitions for specific eating disorders. It is important to keep in mind that just because an adolescent might not fit one of these diagnoses entirely, they may still have a disordered relationship with food that would warrant treatment.

Anorexia Nervosa

The DSM-V includes the following diagnostic criteria for anorexia nervosa (AN):

1. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health

2. Intense fear of gaining weight or of becoming fat or persistent behavior that interferes with weight gain

3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight The DSM-V removed the requirement for AN that a patient have amenorrhea (not applicable to males or to females who have not yet reached menarche) and took out the specific percent ideal body weight, changing the terminology to significantly low’ that does include some indicators in the manual. According to the DSM, prevalence for AN among young women is 0.4% in the course of 12 months. Increasing numbers of males are being diagnosed with AN, but females tend to seek treatment more often.

Bulimia Nervosa

The DSM-V includes the following diagnostic criteria for bulimia nervosa (BN):

1. Recurrent episodes of binge eating characterized by eating an amount of food that is definitely larger than what most individuals would eat in a similar period of time associated with a lack of control over eating during the episode.

2. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

3. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

4. Self-evaluation is unduly influenced by body shape and weight.

5. The disturbance does not occur exclusively during episodes

of AN. While AN has a prevalence of 0.4%, BN is much higher among young females at 1–1.5% according to the DSM.

Binge Eating Disorder

Binge eating disorder (BED) was not an official diagnosis until the DSM-V was released. Previously, patients who binged without purging were grouped into a category called Eating Disorder Not Otherwise Specified. The diagnostic criteria for BED are the following:

1. Recurrent episodes of binge eating characterized by eating an amount of food that is definitely larger than what most individuals would eat in a similar period of time associated with a lack of control over eating during the episode.

2. The binge eating episodes are associated with three (or more) of the following: eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, feeling disgusted with oneself, depressed, or very guilty afterward.

3. Marked distress regarding binge eating is present.

4. The binge eating occurs, on average, at least once a week for

3 months.

5. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in BN and does not occur exclusively during the course of BN or AN.

Avoidant/Restrictive Food Intake Disorder

While many children will grow out of being picky eaters, some will continue to restrict their intake without having concerns about their weight (differentiating it from one of the other eating disorders). Clinically, this is referred to as avoidant/restrictive food intake disorder (ARFID) and is diagnosed as follows:

1. An eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of the following: significant weight loss, significant nutritional deficiency, dependences on enteral feeding or oral nutritional supplements, and marked interference with psychosocial functioning.

2. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.

3. The eating disturbance does not occur exclusively during the course of anorexia or bulimia or better explained by another medical or mental disorder. Sometimes, adolescents with ARFIDhave sensory issues or it can be comorbid with the autism spectrum. Presentations differ, but a few case examples are a teenager who will eat only foods that are soft in texture such as macaroni and cheese and mashed potatoes or one who refuses to eat any fruit or vegetables and rarely eats protein-containing foods, preferring mainly white carbohydrates such as crackers, chips, bread, and rice.

Other Specified Feeding or Eating Disorder

There are some eating disorders that do not fit within the criteria for AN, BN, BED, or ARFID. These eating disorders fall into the category called Other Specified Feeding or Eating Disorder (OSFED) and include atypical AN, subthreshold BN, sub threshold BED, purging disorder, and night-eating syndrome. One example of a patient with OSFED is a teenager whose BMI goes from the 95th percentile down to the 50th percentile in a short period of time. Being at the 50th percentile would preclude them from being ‘significantly low weighted,’ but they might be restricting intake, hyperexercising, or using other unhealthy behaviors that will have an effect on their health.

Orthorexia

According to Mayo Clinic, ‘orthorexia’ comes from the Greek words ‘orthos,’ meaning straight or proper, and ‘orexia,’ meaning appetite. While not an official eating disorder diagnosis, people who become obsessive about eating healthy can have disordered eating patterns and thoughts that can get in the way of living a happy life. Steven Bratman is the doctor who first described and named this disorder. He differentiates healthy eating from orthorexia by the level of obsession that a person has (i.e., whether or not they allow themselves to eat foods they might think of as unhealthy in appropriate situations such as birthday cake at a party).

Celiac and Food Allergies

Food allergies are not specific to adolescence, and in fact, some childhood food allergies may no longer be an issue by the time the child reaches puberty. However, others will persist through childhood into adulthood and may be particularly tricky to deal with during adolescence when a teenager might not want to bring attention to himself or herself by asking about ingredients when out at a restaurant, for example, or carrying an EpiPen. The general public has recently become much more aware of celiac disease and gluten sensitivity. For some, this awareness leads to a diagnosis of celiac disease where the only treatment is to avoid gluten. For others, the hype in the media causes them to needlessly avoid gluten altogether. While a gluten-free diet is an absolutely necessary treatment for someone with celiac disease, gluten (the protein found in wheat, barley, triticale, and rye) should not be removed from the diet without reason. Grain products provide an important source of carbohydrate in addition to being fortified with iron and often good sources of fiber.

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