Adolescent Nutrition

Adolescent NutritionKathryn Camp, MS, RD, CSPKathryn Camp, MS, RD, CSP

Topics for Discussion

Adolescent growth and developmentAdolescent growth and development Psychosocial developmentPsychosocial development Nutritional issues for adolescentsNutritional issues for adolescents

Acute and chronic disease riskAcute and chronic disease risk Influences on adolescent eating Influences on adolescent eating

behaviorsbehaviors Effective nutrition interventionsEffective nutrition interventions

Adolescence:The Vulnerable Life Stage

Big changes: Big changes: BiologicalBiological Boys—get tall, lean, and dense Boys—get tall, lean, and dense

(bones, that is)(bones, that is)Attain 15% of final adult ht Attain 15% of final adult ht during puberty during puberty

Lean body mass doublesLean body mass doublesLarge calorie needs—increase Large calorie needs—increase from 2,000 at 10 yr to 3,000 at from 2,000 at 10 yr to 3,000 at 15 yr15 yr

Adolescence:The Vulnerable Life Stage

Girls—get taller and fatterGirls—get taller and fatter % body fat increases from the teens % body fat increases from the teens

into the mid-20sinto the mid-20s Gain almost 50% of their adult ideal Gain almost 50% of their adult ideal

weight 6-9 mo before ht rate increases weight 6-9 mo before ht rate increases during pubertyduring puberty

Dieting can have a negative impact Dieting can have a negative impact on linear growth during this timeon linear growth during this time

Calorie needs increase by only 200 Calorie needs increase by only 200 from 10 yr to 15 yr from 10 yr to 15 yr

CognitiveCognitive Thinking style changes from Thinking style changes from

concrete to hypothetical and concrete to hypothetical and abstractabstract

““takes the adolescent beyond the takes the adolescent beyond the here and now into the realm of here and now into the realm of possibilities” (David Elkind, possibilities” (David Elkind, 1984)1984)

Identity developmentIdentity development Attempt to figure out who they areAttempt to figure out who they are Success is dependent on positive Success is dependent on positive

interaction with the environment—interaction with the environment—home, school, and the communityhome, school, and the community

They will “try on” different lifestyles They will “try on” different lifestyles looking for the “right fit”looking for the “right fit”

Risk taking behaviors—alcohol, Risk taking behaviors—alcohol, drugs, tobacco, sexual behaviors, drugs, tobacco, sexual behaviors, self-injury and suicideself-injury and suicide•Immediate and severe Immediate and severe

consequences consequences

Behaviors with Less Pronounced Consequences

Eating choices Eating choices Physical activity and exercisePhysical activity and exercise Affect adolescents’ sense of well-Affect adolescents’ sense of well-

being, energy and health in the being, energy and health in the short termshort term

Affect adult-onset chronic disease Affect adult-onset chronic disease risk in the long termrisk in the long term

Another form of Risk-Taking Behavior

Nutrition Issues in Adolescent Health Cardiovascular and cancer disease riskCardiovascular and cancer disease risk Osteoporosis and bone mineralizationOsteoporosis and bone mineralization Overweight and obesityOverweight and obesity Type 2 diabetesType 2 diabetes Eating disordersEating disorders Nutritional needs of the adolescent Nutritional needs of the adolescent athleteathlete Adolescents with chronic medical Adolescents with chronic medical concernsconcerns Adolescent pregnancyAdolescent pregnancy

Part 2

Cardiovascular Disease and Cancer Risk One-third of CVD and cancer-related morbidity One-third of CVD and cancer-related morbidity

attributed to dietary patternsattributed to dietary patterns Diets high in sat fat, total fat, and sodium and low Diets high in sat fat, total fat, and sodium and low

in fiberin fiber Diets low in fruits and vegetablesDiets low in fruits and vegetables

Dietary fatDietary fat Recommended: <10% of calories from sat fat and Recommended: <10% of calories from sat fat and

<30% total fat<30% total fat Consumed: 1/3 of adolescents are in this rangeConsumed: 1/3 of adolescents are in this range

SodiumSodium Recommended: <2.5 g/dRecommended: <2.5 g/d Consumed: 3-5 g/dConsumed: 3-5 g/d NHANES III data; 88-

91, McDowell 94

FiberFiber Recommended: Age + 5Recommended: Age + 5 Consume: ½ this amountConsume: ½ this amount

Fruits and vegetables-Fruits and vegetables- high in fiber and low in fat and sodiumhigh in fiber and low in fat and sodium the least consumed food groups for the least consumed food groups for

teensteens 1/4 eat 2 or more servings of fruit/d1/4 eat 2 or more servings of fruit/d <25% eat at least 5 servings of fruits and <25% eat at least 5 servings of fruits and

vegetables daily vegetables daily Munoz 97, Kennedy 95

Food Ingestion: # 1 on Mom’s ddx

Eating Away from Home

Teens directly spend more thanTeens directly spend more than $5.4 billion in fast food restaurants$5.4 billion in fast food restaurants $9.6 billion in food and snack stores$9.6 billion in food and snack stores $736 million in vending machines$736 million in vending machines

78% in school78% in school Fast foods tend to be low in Fe, Ca, Fast foods tend to be low in Fe, Ca,

riboflavin, vitamin C, and folic acid riboflavin, vitamin C, and folic acid More meals missed at home thus the More meals missed at home thus the

choice of foods away is more choice of foods away is more important than the time or placeimportant than the time or place

Frequency of Fast Food Restaurant Use Among Adolescents (French 01)

Positively associated with Positively associated with Total kcal, % kcal from fat, daily Total kcal, % kcal from fat, daily

servings of soda, cheeseburgers, servings of soda, cheeseburgers, french fries and pizzafrench fries and pizza

Student employment, TV watching, Student employment, TV watching, home availability of unhealthy foods home availability of unhealthy foods

Negatively associated withNegatively associated with Daily servings of fruit, vegs, milkDaily servings of fruit, vegs, milk Perceived maternal and peer Perceived maternal and peer

concerns about healthy eatingconcerns about healthy eating Not associated with overweight statusNot associated with overweight status

Overweight, Obesity, and Type 2 Diabetes

Etiology of Obesity HeritabilityHeritability HomeostasisHomeostasis Specific syndromesSpecific syndromes

Heritability Survival advantage to conserve Survival advantage to conserve

energy as fat through human energy as fat through human evolutionevolution

Humans enriched for genes that Humans enriched for genes that promote energy intake and storage promote energy intake and storage and minimize expenditure.and minimize expenditure.

Enhance female fertility and ability Enhance female fertility and ability to breastfeed offspringto breastfeed offspring

In modern industrial environment In modern industrial environment easy access to calorically dense easy access to calorically dense

foodsfoods encourages sedentary lifestyleencourages sedentary lifestyle

Metabolic consequences of these Metabolic consequences of these genes are maladaptivegenes are maladaptive

Genetic Factors account for 20-40% of heritability of BMI 34 single gene mutations in 83 34 single gene mutations in 83

individuals reported by 2001individuals reported by 2001 > 250 susceptibility genes linked > 250 susceptibility genes linked

with human obesity phenotypeswith human obesity phenotypes

Buchard 97 Rankinen 02

Familial Risk:2-3 fold for moderate obesity5-8 fold for severe obesityBouchard 01

Obesity Associated Syndromes and Conditions

Overweight Prevalence Increasing

Overweight tracks into Adulthood

Overweight Overweight teenagers are teenagers are 4-5 times as 4-5 times as likely to be likely to be obese adults obese adults ((Guo and Chumlea Guo and Chumlea 99)99)

3536 37

39 3843

BMIs of the University of Miami Blocking Machine

Causes of Marked Increase in Overweight Reflects a shift towards positive Reflects a shift towards positive

energy balanceenergy balanceenergy intakeenergy intake = = energy energy expenditureexpenditure

100-300 kcal/d

McDowell 94; Kann 99; Troiano 00,NHANES II to III

PE sed act

Video and computer gamesVideo and computer games Parental work schedulesParental work schedules Unsafe neighborhoodsUnsafe neighborhoods

• discourage parents from allowing discourage parents from allowing children to play outdoorschildren to play outdoors

• force parents to drive children to schoolforce parents to drive children to school Lack of recreational facilities in low-Lack of recreational facilities in low-

income neighborhoodsincome neighborhoods

Other Contributors to Sedentary Lifestyles

Prevalence of Overeating Among 4,746 Adolescents (Ackard 03) 17.3% of girls and 7.8% of boys reported 17.3% of girls and 7.8% of boys reported

overeating and were more likely to:overeating and were more likely to: be overweight or obesebe overweight or obese have dieted in the past yearhave dieted in the past year be currently trying to lose wtbe currently trying to lose wt

Those who met the criteria for binge Those who met the criteria for binge eating syndrome (3% of girls and 1% of eating syndrome (3% of girls and 1% of boys) had higher suicide risk (28% for boys) had higher suicide risk (28% for girls and boys)girls and boys)

Psychological and Economic Consequences of Adolescent Obesity

Discrimination, rejection and low Discrimination, rejection and low self-esteem (Gortmaker 93), self-esteem (Gortmaker 93), particularly for femalesparticularly for females

Less participation in PE and sports Less participation in PE and sports activitiesactivities

Lower college acceptance rates Lower college acceptance rates (Canning 1966)(Canning 1966)

GrowthGrowth Taller, advanced bone age, Taller, advanced bone age,

mature earliermature earlier Early maturation is associated Early maturation is associated

withwithincreased fatness and truncal increased fatness and truncal fat distribution in adulthoodfat distribution in adulthood

Health Issues in Overweigt Adolescents

Hepatic SteatosisHepatic Steatosis Orthopedic ProblemsOrthopedic Problems Sleep Apnea Sleep Apnea

Occurs in 17% of obese children Occurs in 17% of obese children and teens (Marcus 1996)and teens (Marcus 1996)

Deficits in learning, memory, and Deficits in learning, memory, and vocabulary (Rhodes 1995)vocabulary (Rhodes 1995)

Obesity hypoventilation syndrome Obesity hypoventilation syndrome (rare, potentially fatal disorder)(rare, potentially fatal disorder)

Hyperlipidemia--Hyperlipidemia-- LDL and TG, LDL and TG, HDL HDL HypertensionHypertension

Low frequency in childrenLow frequency in children Muscatine Study (Rames 1978)Muscatine Study (Rames 1978)

1% of 6600 children 5 to 18 had 1% of 6600 children 5 to 18 had persistently elevated BPpersistently elevated BP

60% with 60% with BP were >120% of BP were >120% of IBWIBW

Cardiovascular

Type 2 Diabetes 3-10 fold increase in prevalence in 3-10 fold increase in prevalence in

adolescentsadolescents Mean age is 13.5 yrsMean age is 13.5 yrs 95% of teens with Type 2 diabetes have a 95% of teens with Type 2 diabetes have a

BMI >85%ileBMI >85%ile increased insulin resistance increased insulin resistance

21% of adolescents with BMI’s >9521% of adolescents with BMI’s >95thth%ile had %ile had impaired glucose tolerance (Rocchini 02)impaired glucose tolerance (Rocchini 02)

Tremendous public health implicationsTremendous public health implications Longer duration of disease, > risks of Longer duration of disease, > risks of

complicationscomplications

Dabelea 99; Vinicor 00; Richards 85

How Do Teens Attempt to Lose Weight? 1999 Youth Risk Behavior Surveillance1999 Youth Risk Behavior Surveillance

58% exercised58% exercised 40% ate less food or lower fat foods40% ate less food or lower fat foods 13% fasted13% fasted 8% took diet pills8% took diet pills 5% vomited or took laxatives5% vomited or took laxatives

Kann 1999

Weight-Related Eating Disorders

Anorexia nervosaAnorexia nervosaSelf-starvation, Self-starvation, weight loss, intense weight loss, intense fear of weight gain, fear of weight gain, body image distortionbody image distortion

Bulimia nervosaBulimia nervosaBinge eating and Binge eating and purgingpurging

Binge eating Binge eating disorderdisorder

Binge eating Binge eating without purging without purging resulting in weight resulting in weight gaingain

Anorexic andBulemic Behaviors Expressed in 10-20% of adolescent Expressed in 10-20% of adolescent

girlsgirls Mimic behaviors in AN and BN but are Mimic behaviors in AN and BN but are

not done with the frequency or not done with the frequency or severity to classify as mental illnessseverity to classify as mental illness

Half of teen girls and 15% of boys Half of teen girls and 15% of boys report dieting behaviorsreport dieting behaviors Ranging from eating less fat to Ranging from eating less fat to

fasting (Neumark-Sztainer 00)fasting (Neumark-Sztainer 00)

Osteoporosis and Bone Mineralization

Osteoporosis affects 25-30 million Osteoporosis affects 25-30 million adults in the US, women > menadults in the US, women > men 15-25% with hip fractures require 15-25% with hip fractures require

long-term institutional carelong-term institutional care Treatment of osteoporosis costs Treatment of osteoporosis costs

$14 billion/yr$14 billion/yr Etiology complex—genetic, Etiology complex—genetic,

hormonal, physical activity, dietary hormonal, physical activity, dietary factors factors

Maximum peak bone mass (PBM) at Maximum peak bone mass (PBM) at skeletal maturity is protective skeletal maturity is protective

PBM is achieved during the late PBM is achieved during the late stage of pubertal developmentstage of pubertal development 90-95% of PBM is attained by the 90-95% of PBM is attained by the

22ndnd decade of life decade of life 40% of which is during 40% of which is during

adolescenceadolescence

Low bone mineral density is Low bone mineral density is associated with fractures late in associated with fractures late in lifelife

Adequate nutrition, including Adequate nutrition, including energy, protein, vitamins and energy, protein, vitamins and minerals are associated with good minerals are associated with good bone healthbone health

Calcium Milk and dairy products are primary Milk and dairy products are primary

source of calcium in the USsource of calcium in the US Only 49% of boys and 20% of girls Only 49% of boys and 20% of girls

consume the recommended number consume the recommended number of servings from the dairy group.of servings from the dairy group.

AI for calcium for 9-18 yr is 1300 AI for calcium for 9-18 yr is 1300 mg/dmg/d

Girls 14-18 yrs consume 55% of this Girls 14-18 yrs consume 55% of this goal at 713 mg goal at 713 mg 42 mg/d 42 mg/d (Grove 98)(Grove 98)

Calcium Content of FoodsFood ItemFood Item Serving Serving

sizesizeMg calciumMg calcium

Milk or yogurtMilk or yogurt 1 cup1 cup 300 300 CheeseCheese 1 oz1 oz 175-275175-275Ca fort OJCa fort OJ 1 cup1 cup 200-300200-300Salmon w Salmon w bonesbones

3 oz3 oz 180180

Fort. cerealFort. cereal 1 cup1 cup 100100BroccoliBroccoli ½ cup½ cup 47 47 OrangeOrange 1 med1 med 40 40

3 cups milk; 1 oz cheese, ½ c broccoli, 1 orange, 1 c cereal

1300 mg =

Soda Consumption: Effects on body weight, dental health and nutritional status No association with dental No association with dental

caries (Heller 01)caries (Heller 01) 25% of adolescents drink25% of adolescents drink

>26 oz of soda/d>26 oz of soda/d Inverse relationship between Inverse relationship between

intake of nutrients found in milk intake of nutrients found in milk and fruit juice with soda and fruit juice with soda consumptionconsumption Riboflavin, vitamin A, calcium, Riboflavin, vitamin A, calcium,

phosphorus, and vitamin C phosphorus, and vitamin C ((Harnack 99)

Mean Nutrient Intake by Level of Soft Drink Consumption in Adolescents

Soda/d:Soda/d: 0 oz0 oz .1-13 .1-13 ozoz

13-26 13-26 ozoz

>26 oz>26 oz

CaloriesCalories 19841984 21492149 23122312 26042604**Fat Fat % of kcal% of kcal 34 34 ** 3232 3232 3131Folate Folate ugug 239239 238238 191191** 178178**Vit C mgVit C mg 9898 100100 6262** 5252**Calcium Calcium mgmg

819819 804804 652652** 635635**

Riboflavin Riboflavin 2.12.1 1.91.9 1.61.6** 1.51.5*** p<.05 Harnack 99

To Review Risky Adolescent Nutritional Issues Weight gain leading to obesity and type 2 Weight gain leading to obesity and type 2

diabetesdiabetes Calcium intake and soft drink consumption Calcium intake and soft drink consumption

leading to inadequate bone mineralizationleading to inadequate bone mineralization Eating habits that result in disordered Eating habits that result in disordered

eating practiceseating practices Low consumption of fruit and vegetables Low consumption of fruit and vegetables

and high consumption of fat and sodium and high consumption of fat and sodium are related to adult-onset disease riskare related to adult-onset disease risk

“The relationship between the adolescent diet and chronic disease risk is predicated on the assumption that eating behaviors are learned and solidified during childhood and adolescence and are maintained into adulthood” (Lytle 02)

What Influences Adolescents Food Choices? PsychosocialPsychosocial

Strong InfluencesStrong InfluencesFood preferencesFood preferences

•Early childhood experiences, Early childhood experiences, exposure, geneticsexposure, genetics

Taste and appearanceTaste and appearance Weak influenceWeak influence

Health and nutritionHealth and nutrition•Only 26% of college students were Only 26% of college students were

motivated by health when making motivated by health when making dietary choices dietary choices (Horacek 98)(Horacek 98)

The Meaning of Food Study of 93 Canadian adolescent girlsStudy of 93 Canadian adolescent girls Eating “Junk food” was associated Eating “Junk food” was associated

with pleasure, being with friends, with pleasure, being with friends, weight gain, independence, guilt, weight gain, independence, guilt, affordability, and convenience.affordability, and convenience.

Eating “healthful food” was Eating “healthful food” was associated with family, meals, and associated with family, meals, and being at homebeing at home

Chapman 93

Influences cont BiologicalBiological

““I was hungry” is often the first response I was hungry” is often the first response when asked why a specific food was when asked why a specific food was eateneaten

LifestyleLifestyle Time and convenienceTime and convenience

Teens would rather sleep than eat Teens would rather sleep than eat breakfast breakfast (Neumark 99)(Neumark 99)

CostCost In a study of 12 high schools, In a study of 12 high schools,

consumption of fresh fruits and vegs consumption of fresh fruits and vegs when cost was when cost was by 50% by 50% (French 01)(French 01)

More Influences Family—major influenceFamily—major influence

Food providerFood provider Influences food attitudes, Influences food attitudes,

preferences and valuespreferences and values Despite increased eating outside Despite increased eating outside

the home, teens still obtain 65% the home, teens still obtain 65% of their total energy from home.of their total energy from home.

Dinner at home is the most important Dinner at home is the most important mealmeal

80% of parents and teens place high 80% of parents and teens place high importance on this mealimportance on this meal

1/3 of teens eat dinner q night at home1/3 of teens eat dinner q night at home

Effective Nutrition Interventions for Adolescents Behaviorally basedBehaviorally based Use developmentally appropriate Use developmentally appropriate

strategiesstrategies Include an environmental componentInclude an environmental component Sufficient amount of contactSufficient amount of contact Use technological advances such as Use technological advances such as

CD- ROMsCD- ROMsHoelscher, JADA 2002;102:S52

Nutrition Intervention Programs for Adolescents Clueless in the Mall: An interactive Clueless in the Mall: An interactive

web site on calcium for teensweb site on calcium for teens Texas Cooperative Extension Texas Cooperative Extension

ServiceService http://calcium.tamu.edu/http://calcium.tamu.edu/

Committed to Kids: An integrated, 4-Committed to Kids: An integrated, 4-level team approach to weight level team approach to weight management for adolescentsmanagement for adolescents http://www.committed-to-kids.com/http://www.committed-to-kids.com/

Great Beginnings: Nutrition Great Beginnings: Nutrition curriculum for pregnant adolescentscurriculum for pregnant adolescents University of New HampshireUniversity of New Hampshire http://ceinfo.unh.edu/Common/Dochttp://ceinfo.unh.edu/Common/Doc

uments/grtbegin.htmuments/grtbegin.htm Gimme 5: A school-based nutrition Gimme 5: A school-based nutrition

intervention for high school studentsintervention for high school students Baylor College of MedicineBaylor College of Medicine

Adolescent Nutrition JADA, March 2002

Stay Tuned for Part 2