Adolescent Nutrition

K Schroeder, Boston Children’s Hospital, Boston, MA, USA

K Sonneville, University of Michigan, Ann Arbor, MI, USA
ã 2016 Elsevier Ltd. All rights reserved.

Introduction The setting where adolescents eat can have an impact on the
quality of their food intake. A recent review article of family
Adolescence is a time of major physical change. Girls gain an meals found that adolescents who have more frequent family
average of 12.5 pounds per year and boys gain an average of 20 meals also have healthier diets. Higher frequency of family
pounds per year during puberty. Although both gain weight meals is also associated with reduced prevalence of overweight
during adolescence, males have a decrease in body fat percent- and obesity. Unfortunately for many families, evening meals
age to an average of 12% during this time, while females expe- together are not feasible given busy schedules or the lack of
rience an increase to 16–27% body fat. Weight gain is only one interest in these gatherings on the part of the adolescent.
of the countless changes a young person will experience during American adolescents who eat the lunch provided at their
adolescence. The adolescent period is characterized by pro- school will be eating a meal that is nutritionally balanced and
found biological, psychosocial, and cognitive changes. Teens meets the nutrition standards set forth by the National School
are also gaining increasing independence as they grow into Lunch Program. The meal will have no more than 30% calories
young adulthood. Where previously, their parents were making from fat and less than 10% calories from saturated fat. Each meal
the decisions about where, when, and what they would eat, a must provide one-third the recommended dietary allowance
teenager starts to make some of these decisions on their own. (RDA) of protein, vitamin A, vitamin C, iron, calcium, and calories.
Adolescence is a critical period in the development of lifelong Additionally, recent changes to school lunch guidelines involve
health behaviors, and ideally, they have been given the skills to increasing fruits and vegetables and whole grains in school meals.
make healthy choices when confronted with this new-found Skipping meals is prevalent among adolescents, with break-
freedom. Unfortunately, teens that develop unhealthy habits fast being the meal skipped the most often. According to the
may be at risk for serious health consequences. Some problems, YRBSS, 13.7% of teens surveyed had not eaten breakfast 7 days
like obesity, might have started developing at a younger age. preceding the survey and only 38.1% had eaten breakfast on all
Others, like an eating disorder, might only come to light once 7 days. Meal skipping has been associated in numerous studies
puberty occurs and changes start to happen to a person’s body. with risk of overweight and obesity. Nutrition counseling can
The choices that a teenager makes with regard to his or her diet help a teenager identify quick and easy breakfast items for
can have lasting effects; healthy eating can reduce risk of dis- those who cite lack of time in the morning as the main reason
eases such as heart disease, cancer, stroke, and diabetes. that they are missing this important meal. Counseling would
Unhealthy eating can have the opposite effect. also be warranted for a teen who might mistakenly think that
In addition, being a teenager today means being exposed to skipping a meal is an effective strategy for weight loss.
media constantly. From magazines emphasizing the ‘right’ size Snacking is also common among adolescents and has only
for your waistline and social media sites like Facebook and increased over time. The types of snacks showing the biggest
Tumblr allowing teens to view ‘thinspiration’ posts to TV com- increase within this age group are nutrient-poor, energy-dense
mercials and website pop-up advertisements encouraging teens foods including desserts, candy, salty snacks, and sugar-
to drink more soda and eat more fast food, no one can avoid sweetened beverages (SSBs). One study showed that more
being influenced by the media. than 27% of a child’s calories each day came from snacks,
often three or more per day. While snacking is not necessarily
unhealthy, calories should ideally come primarily from bal-
anced meals in addition to small, nutrient-dense snacks
What Are Teenagers Eating?
throughout the day. See articles by Popkin and others, based
on NHANES and Nielsen datasets.
Many teenagers are not meeting the suggested requirements for
major food groups, especially fruit and vegetables. According
to the Continuing Survey of Food Intakes by Individuals and Factors Influencing Food Choice
the National Health and Nutrition Examination Survey, major
contributors to the adolescent diet in the United States include There are many factors that can influence an adolescent’s food
sugar-sweetened beverages, pizza, full-fat milk, grain-based choice; some are external such as peer pressure, and others are
desserts, breads, pasta dishes, and savory snacks. Recent data internal such as cravings. Some are affected by cultural or reli-
from the Youth Risk Behavior Surveillance System (YRBSS) gious beliefs (such as not eating meat during Lent), and others
show that 6.6% of high school students surveyed had not are based purely on availability. A teenager who does not have
eaten a single vegetable 7 days preceding the survey and 5% access to a car, has no nearby grocery store, and mainly shops at a
had not eaten fruit or had 100% fruit juice to drink. A recent neighborhood convenience store is not likely to develop a strong
study on dietary adequacy in teenage girls specifically found affinity towards fresh fruits and vegetables. Current food trends,
that they were lacking in fruits, vegetables, and diary, giving home environment, body image, and health status are other
them lower than adequate intakes (AIs) of calcium, magne- factors that can readily contribute to the decisions that adoles-
sium, potassium, and vitamins D and E. cents make daily regarding food choices.

Encyclopedia of Food and Health http://dx.doi.org/10.1016/B978-0-12-384947-2.00008-8 43

44 Adolescent Nutrition

What adolescents themselves identify as factors that influ- optimal diet. In the United States, the USDA has published
ence their intake do differ from internal/cultural factors that a the MyPlate icon, recommending that everyone eat balanced
teen might not personally think are relevant factors. One focus meals with half of their plates composed of fruits and
group study showed that adolescents identify hunger/food vegetables and the other half divided between protein and
cravings, appeal of food, time, and convenience as the most grains with a serving of dairy at each meal (Figure 1). The
important factors influencing food choices. This same group of Harvard School of Public Health has countered MyPlate with
teenagers identified making healthy food look and taste better their own Healthy Eating Plate (Figure 2), a similar guide that
as the primary suggestion to increase adolescent healthy eating. provides additional guidance such as encouraging the protein
to be healthy (i.e., limiting red meat and high-fat or processed
protein) and grains to be whole grain (i.e., whole-wheat bread,
Dietary Assessment brown rice, and whole-wheat pasta).
The USDA provides suggested servings per day of various
When assessing an adolescent’s diet, it is important to ask spe- food groups as well. See Table 1. For vegetables, the cups given
cific questions. There are several dietary assessment strategies, are intended as cooked vegetables; if eaten raw, the amounts
among which the 24 h recall is the commonly used clinically. should be doubled. For reference, a large banana, orange, or
The 24 h recall involves asking the teenager very specifically peach counts as one cup of a fruit.
about what they ate and drank over the past day including
portion sizes. Depending on the population, it might be worth- Carbohydrates
while to provide a food frequency questionnaire where the teen
can check off how many times per week they eat vegetables and The recommended dietary allowance (RDA) of carbohydrates
how often they drink soda, for example. Some adolescents for adolescents of both genders is 130 g per day. Carbohydrates
might have an easier time remembering what they ate if they provide essential energy to the body, especially for the brain.
are asked to take a photo of each meal or log the meal into an Foods that contain carbohydrate include grains (cereal, bread,
online tracker. The best dietary assessment strategy to use will pasta, rice, oats, tortillas, and pita), starchy vegetables (potatoes,
depend on the adolescent’s nutritional goals. For example, you sweet potatoes, corn, and peas), fruit, dairy, and legumes. The
would not necessarily want a teenager struggling with an eating body stores carbohydrate as glycogen in the muscles and liver.
disorder to track their intake using a website that listed calories.
Fiber
Energy Requirements AI of fiber for males aged 9–13 is 31 g per day, for males aged
Energy requirements for teenagers can vary greatly depending on 14–18 is 38 g per day, and for females aged 9–18 is 26 g per
their physical activity level (PAL) and current stage of growth. The day. Fiber is found naturally in foods such as fruits, vegetables,
Institute of Medicine (IOM) published estimated energy require- beans, legumes, and whole grains. Fiber is essential for main-
ments (EERs) based on a global doubly labeled water database. taining bowel health and for preventing constipation through-
The EER for adolescents 9–18 years of age includes the total energy out the life span. Despite the health benefits of fiber and its
expenditure, in addition to calories needed for energy deposition. availability in multiple food sources, low fiber intake is
For boys, EER is calculated as follows: extremely common among adolescents.

EER ¼ 88:5  ð61:9  age ½y Þ þ PA Protein

 ð26:7  weight ½kg þ 903  height ½mÞ þ 25 kcal
Protein is essential for building and repairing muscles, in addi-
where PA is the physical activity coefficient: tion to other important functions in the body. The RDA for
PA ¼ 1.00 if PAL is estimated to be  1.0 < 1.4 (sedentary).
PA ¼ 1.13 if PAL is estimated to be  1.4 < 1.6 (low active).
PA ¼ 1.26 if PAL is estimated to be  1.6 < 1.9 (active).
PA ¼ 1.42 if PAL is estimated to be  1.9 < 2.5 (very active).

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

Fruits
EER ¼ 135:3  ð30:8  age ½yÞ þ PA Grains
 ð10:0  weight ½kg þ 934  height ½mÞ þ 25 kcal

where PA is the physical activity coefficient: Vegetables

Protein
PA ¼ 1.00 if PAL is estimated to be  1.0 < 1.4 (sedentary).
PA ¼ 1.16 if PAL is estimated to be  1.4 < 1.6 (low active).
PA ¼ 1.31 if PAL is estimated to be  1.6 < 1.9 (active).
PA ¼ 1.56 if PAL is estimated to be  1.9 < 2.5 (very active).

Dietary Guidelines ChooseMyPlate.gov

Various agencies and organizations around the world have

published standards and guidelines for what constitutes an Figure 1 Choose MyPlate.gov.
 Adolescent Nutrition 45

HEALTHY EATING PLATE

Use healthy oil (like WATER Drink water, tea, or coffee

olive and canola oil) (with little or no sugar).
for cooking, on salad, HEALTHY Limit milk/dairy
and at the table. Limit OILS (1-2 servings/day) and
butter. Avoid trans fat. juice (1 small glass/day).
WHOLE
Avoid sugary drinks.
GRAINS
The more veggies- VEGETABLES
and the greater the Eat a variety of whote grains
variety – the better. (like whole-wheat bread,
Potatoes and French fries whole-grain pasta, and
don’t count. brown rice). Limit refined
HEALTHY grains (like white rice
PROTEIN and white bread).
Eat plenty of fruits of all FRUITS
colors. Choose fish, poultry, beans, and
nuts; limit red meat and cheese;
avoid bacon, cold cuts, and
STAY ACTIVE! other processed meats.
© Harvard University

Harvard School of Public Health Harvard Medical School

The Nutrition Source Harvard Health Publications
www.hsph.harvard.edu/nutritionsource www.health.harvard.edu

Figure 2 Harvard School of Public Health Healthy Eating Plate.

Table 1 Select micronutrients suggested intake

Males Females

Nutrient Aged 9–13 Aged 14–18 Aged 9–13 Aged 14–18

Vitamin A (IU per day) 600 900 600 700
Vitamin C (mg per day) 45 75 45 65
Vitamin D (IU per day) 15 15 15 15
Vitamin E (mg per day) 11 15 11 15
Vitamin K (IU per day) 60 75 60 75
Thiamin (mg per day) 0.9 1.2 0.9 1.0
Riboflavin (mg per day) 0.9 1.3 0.9 1.0
Niacin (mg per day) 12 16 12 14
Vitamin B6 (mg per day) 1.0 1.3 1.0 1.2
Folate (IU per day) 300 400 300 400
Vitamin B12 (IU per day) 1.8 2.4 1.8 2.4
Calcium (mg per day) 1300 1300 1300 1300
Iron (mg per day) 8 11 8 15
Potassium (mg per day) 4.5 4.7 4.5 4.7
Sodium (g per day) 1.5 1.5 1.5 1.5

Source: National Research Council. (2006). Dietary Reference Intakes: the essential guide to nutrient requirements. Washington, DC: The National Academies Press

adolescent boys aged 9–13 is 34 g per day and for adolescent

Fat
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 It is necessary for the diet to contain fat in order to help absorb
found in animal products such as meat, poultry, fish, dairy, fat-soluble vitamins (vitamins A, D, E, and K) and to provide
and eggs and in beans, legumes, and nuts. linoleic acid and linolenic acid, essential for neurological
46 Adolescent Nutrition

Table 2 Recommended fruit and vegetable intake Supplements and Alcohol

Gender and age Fruit servings Vegetable servings Energy Drinks

Girls 9–13 1 ½ Cups 2 Cups Energy drinks such as Red Bull, 5-Hour ENERGY, and Monster
Girls 13–18 1 ½ Cups 2 ½ Cups Energy drink are a growing product category that seems to
Boys 9–13 1 ½ Cups 2 ½ Cups appeal to adolescents. Studies have shown not only that there
Boys 13–18 2 Cups 3 Cups are potential negative health effects to the energy drinks
themselves but also that those adolescents who consume
Source: www.choosemyplate.gov. energy drinks are at higher risk of substance use such as smok-
ing, drinking alcohol, and using illicit drugs. The American
development and growth. The acceptable macronutrient distri- Academy of Pediatrics recommends that children and adoles-
bution range for fat for teenagers of both genders is 25–35 g cents avoid consuming energy drinks, suggesting that they use
per day. Adolescents should attempt to eat as little trans fat as water as their primary source of hydration.
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. Alcohol
According to a recent YRBSS report, 66.2% of high school
students reported having had at least one alcoholic drink in
Vitamins and Minerals their life. During the 30 days prior to the survey, 34.9% of
teenagers had consumed alcohol at least once and 20.8% had
Certain vitamins and minerals have a recommended dietary had five or more drinks in one sitting, the definition of binge
allowance (RDA), while others have only an established AI drinking. Teen consumption of alcohol remains a problem for
because no RDA has been established. See Table 2 for a list of many reasons. According to the American Academy of Pediat-
select vitamins and minerals and the suggested intake levels for rics, alcohol can interfere with adolescent brain development,
adolescents. Most of these nutrients can be consumed in these which continues into young adulthood. In addition, using
suggested amounts by eating a balanced, varied diet that alcohol during adolescence can promote the risk of alcoholism
includes fruit and vegetables. In the absence of adequate por- later in life, can lead to motor vehicle-related fatalities (the
tions of these healthy foods, however, a multivitamin or other leading cause of death among US teens), and can lead to
supplement may be warranted. other mental and physical disorders. From a nutritional per-
One particular nutrient of special importance during ado- spective, alcohol provides excess calories, which when con-
lescence is calcium, which is aided in absorption by vitamin D. sumed in large quantities can lead to overweight and obesity.
Adequate calcium intake during adolescence is key for prevent- Alcohol consumption is also often associated with poor dietary
ing osteoporosis because childhood and adolescence are the choices, and long-term use can affect the absorption of certain
time when bones are gaining strength and density that cannot vitamins and minerals.
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
Obesity
vegetables, and fortified foods such as cereal and snack bars.
The criterion for children aged 2–20 for overweight is a BMI
between the 85th and 95th percentile according to Centers for
Hydration Disease Control and Prevention growth charts. For obesity, the
criterion is a BMI over the 95th percentile. Obesity rates among
The Holliday–Segar method of figuring hydration needs is
adolescents have increased significantly over the past fourteen
used in hospitals but can also be applied to healthy adoles-
years. An article looking at the prevalence and trends in obesity
cence. The equation is as follows:
and severe obesity showed that from 2011 to 2012, 17.4% of
children aged 2–19 were obese and prevalence among adoles-
Patient weight Fluid needs
cents exceeded 20%. Prevalence of severe obesity is also grow-
11–20 kg 1000 ml þ 50 ml kg1 for each kg >10 kg ing among youth aged 2–19 with 5.9% meeting criteria for
>20 kg 1500 ml þ 20 ml kg1 for each kg >20 kg 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
The daily recommended intake (DRI) can also be used to than or equal to 140% of the 95th percentile or a BMI of greater
determine the recommended fluid intake for teenagers. For than or equal to 40).
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
Sugar-Sweetened Beverages
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 According to YRBSS data, 27% of teenagers had consumed one
other beverages, in addition to liquids and moisture in foods nondiet soda per day 30 days leading up to the survey, and
such as soup, watermelon, and cucumber. even more worrisome, 19.4% had consumed nondiet soda two
 Adolescent Nutrition 47

or more times per day. SSBs include juice, lemonade, punch, Polycystic Ovary Syndrome
soda, and other drinks that adolescents consume on a regular
PCOS is a disease that affects 7–14% of adult women (depend-
basis. These beverages (with the possible exception of juice)
ing on the diagnostic criteria used), with the onset happening
provide no nutritional value, but contain a large amount of
mainly during adolescence. While no specific causes of PCOS
calories. This is often referred to as ‘empty’ calories because
have been definitively identified, childhood obesity is thought
they are providing nothing besides energy. Soda is often vili-
to be a contributing factor. PCOS is often associated with
fied when discussing causes of increased obesity in society.
obesity, metabolic syndrome, and type 2 diabetes; it is charac-
Indeed, the serving sizes have grown larger over the years,
terized by irregular periods, hirsutism, acne, weight gain, and
and the marketing does directly target young people. One
acanthosis nigricans. Weight loss can reduce some symptoms,
recent study of SSBs on adolescents linked increased intake
but elevated insulin levels may make weight loss more difficult
with greater waist circumference, a risk factor for metabolic
for adolescent girls who have PCOS compared with their
syndrome. However, it is important to remember that while
healthy counterparts. Adolescent girls with PCOS can manage
SSBs can contribute to excess calories, it is often only one piece
their insulin levels by decreasing the amount of refined carbo-
of the obesity puzzle.
hydrates they eat or drink, increasing the amount of protein
and fiber in their diet, and getting plenty of physical activity.

Screen Time
Eating Disorders
There is strong relationship between screen time and excess
weight gain/obesity in children and adolescents. Whether this Adolescence is a particularly hard time for a person to deal with
is due to the effects of commercials advertising to teens on body image issues since there are so many changes happening
television, the fact that one often mindlessly consumes calories to the body during puberty. This can set the stage for an eating
when in front of a screen, the lack of physical activity due to disorder that may not have been an issue previously. While any
screen time, or the effect that screen time has on sleep, experts disordered relationship with food can be considered an eating
agree that less screen time is beneficial to all children and teens, disorder of concern, there are differing levels of clinical sever-
especially those at risk of overweight or obesity. ity. 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 impor-
Extreme Dieting tant to keep in mind that just because an adolescent might not
fit one of these diagnoses entirely, they may still have a disor-
According to the recent YRBSS data, 47.7% of teenagers dered relationship with food that would warrant treatment.
reported that they were trying to lose weight with females
being more likely to report this than males. Of concern, 13% Anorexia Nervosa
of students reported that they had not eaten for twenty-four or
more hours in an attempt to lose weight and 5% reported The DSM-V includes the following diagnostic criteria for
having taken diet pills. Additionally, 4.4% reported vomiting anorexia nervosa (AN):
or taking laxatives to lose weight or keep from gaining weight. 1. Restriction of energy intake relative to requirements, lead-
Extreme dieting does not work and often leads to a heavier ing to a significantly low body weight in the context of age,
weight in the long run. In addition, it can cause numerous sex, developmental trajectory, and physical health
health issues and nutritional deficiencies. For more 2. Intense fear of gaining weight or of becoming fat or persis-
information, see the section on ‘Eating Disorders.’ tent 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
Type 2 Diabetes shape on self-evaluation, or persistent lack of recognition of
the seriousness of the current low body weight
Type 2 diabetes, also referred to as non-insulin-dependent
diabetes as a way of differentiating it from type 1 diabetes The DSM-V removed the requirement for AN that a patient
(previously called juvenile diabetes), is an increasing problem have amenorrhea (not applicable to males or to females who
among children and adolescents commonly caused by obesity. have not yet reached menarche) and took out the specific
In the past, this type of diabetes was called adult-onset percent ideal body weight, changing the terminology to
diabetes, but that name is no longer accurate due to the rising ‘significantly low’ that does include some indicators in the
number of diagnoses in younger populations. In addition to manual. According to the DSM, prevalence for AN among
obesity, several comorbidities such as proteinuria (protein in young women is 0.4% in the course of 12 months. Increasing
the urine), hypertension, dyslipidemia, nonalcoholic fatty liver numbers of males are being diagnosed with AN, but females
disease, polycystic ovary syndrome (PCOS), and obstructive tend to seek treatment more often.
sleep apnea are seen among adolescent with type 2 diabetes.
There are currently few treatments for type 2 diabetes in ado-
Bulimia Nervosa
lescents that include lifestyle changes (eating a healthy, bal-
anced diet plus exercising regularly), pharmacology, and The DSM-V includes the following diagnostic criteria for
gastric bypass surgery. bulimia nervosa (BN):
48 Adolescent Nutrition

1. Recurrent episodes of binge eating characterized by eating 2. The disturbance is not better explained by lack of available
an amount of food that is definitely larger than what most food or by an associated culturally sanctioned practice.
individuals would eat in a similar period of time associated 3. The eating disturbance does not occur exclusively during
with a lack of control over eating during the episode. the course of anorexia or bulimia or better explained by
2. Recurrent inappropriate compensatory behaviors in order another medical or mental disorder.
to prevent weight gain, such as self-induced vomiting; mis-
Sometimes, adolescents with ARFID have sensory issues or it can
use of laxatives, diuretics, or other medications; fasting; or
be comorbid with the autism spectrum. Presentations differ, but
excessive exercise.
a few case examples are a teenager who will eat only foods that
3. The binge eating and inappropriate compensatory behav-
are soft in texture such as macaroni and cheese and mashed
iors both occur, on average, at least once a week for 3
potatoes or one who refuses to eat any fruit or vegetables and
months.
rarely eats protein-containing foods, preferring mainly white
4. Self-evaluation is unduly influenced by body shape and
carbohydrates such as crackers, chips, bread, and rice.
weight.
5. The disturbance does not occur exclusively during episodes
of AN. Other Specified Feeding or Eating Disorder
While AN has a prevalence of 0.4%, BN is much higher among There are some eating disorders that do not fit within the criteria
young females at 1–1.5% according to the DSM. 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-
Binge Eating Disorder threshold BED, purging disorder, and night-eating syndrome.
One example of a patient with OSFED is a teenager whose BMI
Binge eating disorder (BED) was not an official diagnosis until
goes from the 95th percentile down to the 50th percentile in a
the DSM-V was released. Previously, patients who binged with-
short period of time. Being at the 50th percentile would preclude
out purging were grouped into a category called Eating Disor-
them from being ‘significantly low weighted,’ but they might be
der Not Otherwise Specified. The diagnostic criteria for BED
restricting intake, hyperexercising, or using other unhealthy
are the following:
behaviors that will have an effect on their health.
1. Recurrent episodes of binge eating characterized by eating
an amount of food that is definitely larger than what most
‘Orthorexia’
individuals would eat in a similar period of time associated
with a lack of control over eating during the episode. According to Mayo Clinic, ‘orthorexia’ comes from the Greek
2. The binge eating episodes are associated with three (or words ‘orthos,’ meaning straight or proper, and ‘orexia,’ mean-
more) of the following: eating much more rapidly than ing appetite. While not an official eating disorder diagnosis,
normal, eating until feeling uncomfortably full, eating people who become obsessive about eating healthy can have
large amounts of food when not feeling physically hungry, disordered eating patterns and thoughts that can get in the way
eating alone because of feeling embarrassed by how much of living a happy life. Steven Bratman is the doctor who first
one is eating, feeling disgusted with oneself, depressed, or described and named this disorder. He differentiates healthy
very guilty afterward. eating from orthorexia by the level of obsession that a person
3. Marked distress regarding binge eating is present. has (i.e., whether or not they allow themselves to eat foods
4. The binge eating occurs, on average, at least once a week for they might think of as unhealthy in appropriate situations such
3 months. as birthday cake at a party).
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. Other Nutritional Issues in Adolescents
Female Athlete Triad
Avoidant/Restrictive Food Intake Disorder Female teenage athletes are especially at risk for the female
athlete triad. In the past, this triad was considered to be eating
While many children will grow out of being picky eaters,
disorder, amenorrhea, and osteoporosis. Now, however, it is
some will continue to restrict their intake without having
considered to be more of a continuum, with low energy avail-
concerns about their weight (differentiating it from one of
ability taking the place of eating disorder, implying that the
the other eating disorders). Clinically, this is referred to as
athlete does not necessarily have an eating disorder but is for
avoidant/restrictive food intake disorder (ARFID) and is diag-
whatever reason not taking in enough calories that is causing
nosed as follows:
the functional amenorrhea that then causes the low bone
1. An eating or feeding disturbance as manifested by persistent mineral density. Female athletes should be screened for the
failure to meet appropriate nutritional and/or energy needs female athlete triad on a regular basis to prevent any interfer-
associated with one or more of the following: significant ence with bone growth and development. If a female athlete
weight loss, significant nutritional deficiency, dependences has amenorrhea, nutrition counseling is warranted to identify
on enteral feeding or oral nutritional supplements, and ways that she can consume adequate calories in order to
marked interference with psychosocial functioning. resume menses.
 Adolescent Nutrition 49

Iron-Deficiency Anemia Future Trends in Adolescent Nutrition

During adolescence, teens have increased iron needs due to
As teenagers across the world continue to be influenced by
normal growth and development. Girls in particular have
popular media and increasingly by various forms of social
increased iron needs due to the blood loss during menstrua-
media, diet trends will likely continue to affect their foods
tion. Because of this, adolescents are more susceptible than
choices, body image concerns, and health habits. Practices
adults to iron-deficiency anemia, which is characterized by
like juice cleansing, fasting, eating clean, consuming only
not enough or especially small red blood cells. To prevent
organic foods, and cutting out items like sugar, gluten, and
iron-deficiency anemia, adolescents should make sure to
dairy without being medically advised to do so are just a few of
include iron-rich food sources in their diet including red
the trends that adolescents are starting to follow. Whatever
meat, eggs, poultry, fish, legumes, and fortified breads and
popular media decides as the next big weight loss secret or
cereals. Girls and boys aged 9–13 need 8 mg per day, boys
key to having clear, glowing skin will be seen before too long
aged 13–18 need 11 mg per day, and girls aged 13–18 need
in the adolescent population. With any luck, these same teens
15 mg per day. Consuming foods rich in vitamin C (such as
will also have a caring, educated community supporting him or
fruits and vegetables) in conjunction with iron-containing
her to provide education on healthy, balanced, adequate
foods can help with the absorption of iron.
nutrition.

Vegetarianism/Veganism
See also: Anemia: Causes and Prevalence; Anemia: Prevention and
As with any population including growing children, adoles- Dietary Strategies; Appetite Control in Humans: A Psychobiological
cents can eat a healthy, varied, and balanced vegetarian or Approach; Beverage: Health Effects; Bioavailability of Nutrients;
vegan diet that will provide all of the necessary nutrients that Caffeine: Consumption and Health Effects; Cystic Fibrosis, Nutrition in;
they need for growth. With adolescents who might already Dietary Practices; Dietary References: US; Eating Disorders; Energy:
have suboptimal nutritional intake, however, extra precautions Intake and Energy Requirements; Energy Metabolism; Food Allergies;
are necessary to ensure that they are actually consuming Growth promoters: Characteristics and Determination; Hunger; Obesity:
enough of each nutrient on an animal-free diet, specifically Causes and Prevalence; Obesity: Epidemiology of; Obesity
protein, calcium, B12, vitamin D, and iron. Many products Management; Obesity: The Role of Diet; Protein: Requirements; Satiety;
that are available to vegetarians and vegans are fortified with Sports Nutrition; Vegetarian Diets; Vitamins: Overview.
some of these important nutrients, but assessment and moni-
toring by a dietitian may be warranted. It is also important to
assess why a teenager has chosen to become a vegetarian. In
some cases, eliminating meat and/or dairy could be the begin- Further Reading
ning of a restrictive eating disorder. In general though, a vege-
American Dietetic Association (2011) Position of the American dietetic association:
tarian diet can be a healthy option for an adolescent. One study nutrition intervention in the treatment of eating disorders. Journal of the American
showed that vegetarian teenagers had better fruit and vegetable Dietetic Association 111: 1236–1241.
consumption and less total and saturated fat consumption Barlow SE and the Expert Committee (2007) Expert committee recommendations
than their meat-eating peers. regarding the prevention, assessment and treatment of child and adolescent
overweight and obesity: summary report. Pediatrics 120: S164–S192.12.
Berlan ED and Emans SJ (2009) Managing polycystic ovary syndrome in
adolescent patients. Journal of Pediatric and Adolescent Gynecology
Celiac and Food Allergies 22: 137–140.
Center for Disease Control (2014) Adolescent and School Health. Nutrition and the
Food allergies are not specific to adolescence, and in fact, some health of young people. http://www.cdc.gov/healthyyouth/nutrition/facts.htm.
childhood food allergies may no longer be an issue by the time Field AE, Austin SB, Taylor CB, et al. (2003) Relation between dieting and
weight change among preadolescents and adolescents. Pediatrics
the child reaches puberty. However, others will persist through
112: 900–906.
childhood into adulthood and may be particularly tricky to Field AE, Camargo CA, Taylor CB, Berkey CS, Roberts SB, and Colditz GA (2001) Peer,
deal with during adolescence when a teenager might not want parent, and media influences on the development of weight concerns and
to bring attention to himself or herself by asking about ingre- frequent dieting among preadolescent and adolescent girls and boys. Pediatrics
dients when out at a restaurant, for example, or carrying an 107: 54–60.
Freedman DS, Mei Z, Srinivasan SR, Berenson GS, and Dietz WH (2007) Cardiovascular
EpiPen. risk factors and excess adiposity among overweight children and adolescents: the
The general public has recently become much more aware bogalusa heart study. The Journal of Pediatrics 150: 12–17.
of celiac disease and gluten sensitivity. For some, this aware- Larson N and Neumark-Sztainer D (2009) Adolescent nutrition. Pediatrics in Review
ness leads to a diagnosis of celiac disease where the only 30: 494–496.
Neumark-Sztainer D, Wall M, Larson NI, Eisenberg ME, and Loth K (2011) Dieting and
treatment is to avoid gluten. For others, the hype in the
disordered eating behaviors from adolescence to young adulthood: findings from a
media causes them to needlessly avoid gluten altogether. 10-year longitudinal study. Journal of the American Dietetic Association
While a gluten-free diet is an absolutely necessary treatment 111: 1004–1011.
for someone with celiac disease, gluten (the protein found in Ogden CL, Carroll MD, Kit BK, and Flegal KM (2014) Prevalence of childhood and adult
wheat, barley, triticale, and rye) should not be removed from obesity in the United States, 2011-2012. JAMA 311: 806–814.
Sonneville K and Duggan C (2014) Manual of pediatric nutrition, 5th ed. Shelton, CT:
the diet without reason. Grain products provide an important People’s Medical Publishing House.
source of carbohydrate in addition to being fortified with iron Stang J and Story M (2005) Nutrition needs of adolescents. In: Stang J and Story M
and often good sources of fiber. (eds.) Guidelines for adolescent nutrition services, pp. 21–34. Minneapolis, MN:
50 Adolescent Nutrition

Center for Leadership, Education and Training in Maternal and Child Nutrition, Relevant Websites
Division of Epidemiology and Community Health, School of Public Health,
University of Minnesota. http://kidshealth.org/teen/ – TeensHealth from Nemours.
Swanson SA, Crow SJ, Le Grange D, Swendsen J, and Merikangas KR (2011) http://win.niddk.nih.gov/publications/take_charge.htm – WIN Weight-control
Prevalence and correlates of eating disorders in adolescents. Archives of General Information Network: Take Charge of Your Health, A Guide for Teenagers.
Psychiatry 68(7): 714–723. http://www.nutrition.gov/life-stages/adolescents/tweens-and-teens – Nutrition.gov for
Tanner JM (1962) Growth at adolescence, 2nd ed. Oxford: Blackwell Scientific Tweens and Teens.
Publications. http://www.youngwomenshealth.org/ – Center for Young Women’s Health.