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1. Obesity during adolescence has become a major public health problem in the US, with
twice as many teens being affected. I was a normal weight child, but an overweight
teenager; and have been battling my weight ever since then.
2. While genetics does play a role, it is believed that the interactions between genetics
and environmental factors plays a bigger role. Thus in genetically susceptible teenagers,
behaviors such as consuming high calorie foods and not being physically active can lead
to obesity.
3. Obesity is not just about energy balance though. Parents who are overweight pass
down both their obesity genes and their poor behaviors that enable a teenager to
follow the same pattern.
4. Not having enough money to buy healthy food, as well as the time or skills to cook
healthy food, can also impact a teenager’s weight.
5. Studies in difference races and ethnicities shows that while there are genetic
components to their increased prevalence to obesity, there are also cultural practices
and changes in environments that leads to the obesity. In addition, some recent studies
show that when socioeconomics are controlled for, racial differences in obesity are no
longer significant.
6. Just like we saw in childhood, a teenager with a condition like cerebral palsy who is
confined to a wheelchair is at risk of obesity due to their forced limitations in physical
activity.
7. African American young women and Hispanic young men have the highest prevalence
of being overweight and obese.
8. Also note that an overweight adolescent is much more likely to stay overweight or
become obese into adulthood than an overweight preschooler or younger child. This is
why it is important to correct these problems early.

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1. The same categories exist in adolescences as we saw in school-aged children and
preschoolers.
2. BMI is still fluctuating during adolescence, as growth spurts and changes in body
composition are occurring. Therefore it is important to compare BMI for both age and
gender when determining status. CDC growth charts can be found at
www.cdc.gov/growthcharts.

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1. Obesity at all ages increases the risk for many other diseases related to altered fat or
carbohydrate metabolism.
2. The issues of poor body image and low self esteem are heightened during adolescence,
as teenagers are trying to fit in with their peers.

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1. This flow chart shows how all adolescents are screened yearly to check for overweight
and obesity.
2. If an adolescent is overweight than they need a more in depth assessment for other
related conditions. For example: Fasting lipid levels, AST and ALT (liver function tests),
fasting glucose levels, microalbumin (protein in urine, suggesting kidney disease).

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1. Adolescents need yearly screening for obesity. This table details how BMI is calculated
and why you can’t use the adult values.

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1. The goal in most overweight children is to maintain weight while they grow in
height.
2. Obese children should lose no more than 2 Ibs per week regardless of
the severity of the obesity.
3. If a child begins losing weight too quickly than you need to screen for
an eating disorder.

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1. This is the same staged approach that was recommended in younger children. The
intervention gets more intense with each stage until results are seen.
2. Each stage is discussed here in more depth, as adolescents are better able to
understand the later stages.
3. Stage 1 focuses on emphasizing all of the same prevention messages that are
encouraged for all children and teens. It is used for an overweight child or teenager.
4. This teenager would only need to work with one health care provider, who will
reinforce overall healthy lifestyle.

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1. Stage 2 treatment increases the level of structure and accountability.
2. While any of the health care professionals can perform stage 2
counseling it requires behavioral pediatric weight management
training.
3. Refer teenagers when necessary to: physical therapy, mental health counseling, and
medical nutrition therapy (RD).

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1. The next stage is to enter into an 8-12 week program that is followed by bimonthly
visits until weight loss is achieved.
2. There is more structure and a real team approach.

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1. These are extreme measures for severe obesity that are not recommended for younger
children. There are many more risks involved in these treatments and the teenager
needs to be able to understand the risks as well as be committed to follow the
treatments completely.
2. This should be done at a tertiary weight-management center. One diet is a protein
sparing modified fast. This diet is low calorie, low carbohydrate (20g), with a goal of
putting the patient in a state of ketogenesis. In this state fat is being converted into
ketones for the brain to use and other tissues are using fat for fuel. Higher protein is
provided such that growth can continue. This diet is used as an intermediate treatment
between diet/exercise and surgery. The severe food restrictions should only occur for
12 weeks, but the diet can be transitioned to include more carbohydrates and followed
outpatient. Adolescents can stay on this long term, as a glorified Atkin’s diet. This diet
can be done in children too young for surgery.
3. Risks associated with very-low-energy diets or meal replacements are: orthostatic
hypertension (dizziness when standing), diarrhea, hyperuricemia, cholelithiasis,
electrolyte imbalance, impaired renal and liver function, cardiac arrhythmias, and
reduced serum protein levels. Thus, it is best to do this diet in an in-patient center.
4. Orlistat blocks fat absorption, which also reduces fat soluble vitamin absorption and
potential deficiency.
5. Metformin enhances insulin sensitivity, alters glucose metabolism, and may reduce
food intake. Studies suggest that metformin may improve weight loss and prevent
diabetes in adolescents with significant insulin resistance.

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1. This is only recommended for mature teenagers that have passed their growth spurt.
This is defined as being at 95% predicted adult height and Tanner Stage IV or V. The
teenager needs to not only be obese, but also have additional conditions, such as
diabetes.
2. Only the less severe surgeries are performed on teenagers, including the Roux-en Y
gastric bypass and the sleeve gastrectomy.
3. The post-operative diet is high in protein, moderate in fat, and devoid of all simple
sugars and carbohydrates. Supplemental vitamins and minerals are also required.
Nutrients that should be assessed include: protein, iron, calcium, vitamins D, B6, B12,
thiamin, and folic acid. Fluid intake is also important, as there is an increased risk for
dehydration.

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1. The initial diet right after surgery is all liquid with lots of protein to encourage healing
and reduce dumping syndrome. Dumping syndrome is when food moves too fast from
the stomach to the intestine.
2. Next the diet is transitioned to increase volume and texture of the food. Then you can
start adding solid foods slowing. This can take up to 6 months to get to solid foods.
3. Since the size of the stomach is small, it is recommended that 3-4 small meals are
consumed. The high protein helps reduce the dumping syndrome.
4. Consuming fluid not with meals also helps reduce dumping syndrome.
5. This same diet of 3-4 small high protein meals with lots of sugar-free beverages is then
continued long term.
6. Physical activity is recommended to aid in the weight loss.
7. Micronutrients need to be supplemented including: a daily multivitamin that contains
folate and iron; 1000 mcg vitamin B12 daily until blood levels normal, then annual
injections of 3000 mcg; 1200-1500 mg calcium; and 800-1000 IU vitamin D. Thiamine
(50 mg/d) is given if there is a lot of nausea and vomiting. Other micronutrients can be
provided as needed if vomiting.
8. Nutrient assessment includes annual assessments of nutrient status. Iron status is
checked by looking at serum iron and ferritin. Red blood cell folate is measured.
Homocysteine assesses folate and B12 status. Serum vitamin B12 and thiamine are also
measured. Albumin assesses protein status. Alkaline phosphatase assesses phosphorus.
PTH assesses the regulation of calcium, vitamin D, and phosphorus.

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1. Use Total energy expenditure (TEE) to calculate energy needs in place of EER or Mifflin
St. Jeor formula in overweight and obese people.

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1. The adolescents who are taking vitamin and mineral supplements are
the ones who are eating a healthy diet and do not need them.
2. The risks and side effects of ergogenic supplements is greater than
their benefits, which is why these are banned in National and NCAA
regulations. But high schools rarely test for these substances and
younger teenagers are not mature enough to understand the risks.
Their use peaks in 9th/10th grade.
3. Creatine is a nutritional supplement used to increase lean body mass.
The data is mixed in adults that it has any effect to improve
performance. There is very little data in adolescents. The side effects
include GI upset, headache, dehydration, reduced renal function,
increased tendency to get muscle strains and muscle soreness.
4. There are also other pre-workout supplements that are taken by
adolescents. During your assessment you should have them bring in
the item and look at the label, as there are so many different ones.

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1. Each adolescent will need a unique amount of energy and protein depending the the
actual amount of increased physical activity that they are doing.
2. If weight loss is an issue than have the teen weight themselves before and after an
event to measure this.

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1. Determining the needs starts with the general recommendations based on Sexual
Maturation Rating, then add calories based on the intensity and duration of activity.
The new 2015 dietary guidelines separates activity into sedentary, moderate activity
and very active, which provides a better starting point.
2. No one has determined scientifically exactly how much more is really needed. Make
your best estimate then follow weight before and after an event. If weight loss is not
transient than it means that more calories are needed.

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1. Here are some recommendations for fueling up before an athletic event.
2. Foods high in: fat, protein, and dietary fiber should not be consumed within 4 hours of
an event due their slow absorption.
3. After an event meals include 400-600 calories, should be high carbohydrate, and non-
caffeinated fluid.

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1. Because athletes break their bones more often, it is essential that they consume
enough calcium.
2. The Texas Dairy Council promotes chocolate milk– Contains Calcium, protein,
potassium, sodium, and magnesium

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1. Fluids lost during strenuous exercise need to be replaced. But too
much water can also be bad.
2. Water is best for more short term activities. For prolonged strenuous
activity sports drinks and dilute fruit juice is important. These provide
electrolytes and a little energy. The carbohydrates also increases the
rate of water absorption.

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A local teenager was rushed to the hospital and nearly died from water intoxication. DeJuan Garrett says he did it
because his coach told him to do so.
The 15-year-old wrestler is a sophomore at Southfield Lathrup High School. Garrett has been wrestling since the age of
eight. His mother is proud and says her son is a natural.
"That's something that he excelled in and did very well," said Felica Cheeks, his mother, who added that last year he was
Southfield Lathrup's district champ.
There have never been any problems with his wrestling program until Thursday at practice. Cheeks got a phone call that
Garrett fainted.
"When I got to the hospital, I was told that my son was in critical condition," Cheeks said. "I couldn't understand how
from fainting you ended up on a respirator."
"His brain swelled. He had a seizure and then was non-responsive to stimuli. Basically, within an hour and a half time if
it's not treated you die," she added. "His father tried to reassure me our son was fine, but his coach told me and I quote,
"Mam, all I did was give him water at practice."
Water -- it does not seem like anything would be wrong with that.
"Not once the whole time that we sat there did he tell me that my son consumed eleven, twelve-ounce bottles of water,"
said Cheeks. "The doctor explained (to) me that he was suffering from water intoxication, that he had (drunk) too much
water."
In just two hours, she says, and her son weighs less than 100 pounds.
"The proper way to hydrate them is over time," Cheeks said. "He was not exercising. He was not practicing. The only thing
that he was doing during that two hour practice was drinking water."
"My legs started hurting and then I couldn't feel them. Then I feel to my knees (and) then I fell down. Then I threw up and
I couldn't see," said Garrett. "It was scary."
Garrett is okay now and still has the utmost respect for his coach. One of his teammates seems to understand why.
"It was unfortunate," he said. "I think coach wanted the best for the child."
"He's like the second best coach I ever had. He helped me. If it wasn't (for) him, I never (would have) won district last
year," Garrett said.
"I understand that coach didn't intentionally try to bring any harm to my son, but knowledge is something that every
coach should have if you're going to be dealing with kids and their health because that's ultimately what you're doing. I
don't want this to happen to somebody else's child," said Cheeks.
We put calls into the Southfield School District, but have not heard anything back yet. We also went to the school board
meeting Tuesday night to see if any board member had anything to say. They did not even know about it.
Posted: Dec 14, 2010 10:36 PM EST
Fox 2 new headlines
Thus, it is important to stay hydrated during sports, but too much water too fast is also bad.

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1. Different athletes have different methods for carbohydrate loading.
The classic approach is to start a week before a big event. The first 3
days involve intense training and a low carbohydrate diet to deplete
glycogen stores. Then the three days before the event you consume
high carbohydrate meals and train less. My friend Valarie competed in
triathlons when we were in college. She simply ate a very high
carbohydrate meal the night before the race.
2. High protein diets are discouraged for three reasons. 1. Many high
protein foods are high in saturated fats. 2. High protein and fat
consumption will delay carbohydrate absorption, limiting energy
availability during activity (less glycogen). 3. Protein metabolism uses
more water, which could lead to dehydration during an athletic event.

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1. Cigarette smoking and some illicit drugs can reduce appetite. Alcohol
consumption frequently replaces food intake. Plus the foods chosen
while under the influence are not healthy.
2. The absorption rate of many B vitamins, such as thiamin, is reduced
by alcohol.
3. Cigarette smoking increases oxidative stress and leads to an
increased need for some antioxidant micronutrients, such as vitamin
C.

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1. Adolescents have iron deficiency anemia more than any other nutritional deficiency.
2. There are several risk factors in teens because they are: a. rapidly growing; b. choosing
their own dietary patterns, which may not include good sources of iron or vitamin C; c.
exercising more intensely, which increases blood and iron loss; and d. young women are
beginning to lose blood each month with menstruation.
3. Because iron is essential for energy metabolism and oxygen transport there are many
side effects of deficiency, which are similar to other age groups.

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1. All adolescent females need to be screened every 5 years if they have no risk factors; or
every year if they have at least one risk factor.
2. Adolescent males are only screened if they have a risk factor.
3. Also note that in practice anemia is assumed to be caused by iron, even though we
know that many different nutrient deficiencies can lead to anemia.
4. Note how the cut off values for anemia change with age. This is due to differences in
blood volume during growth.

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1. Lean meats and fish are the best source of easily absorbed iron.
2. Iron is also present in some plant foods such as spinach, other dark green leafy
vegetables, beans, raisons and other dried fruit. But iron from plant foods is not
absorbed as well. Consuming vitamin C with the plant based foods aids its absorption.
3. Most cereals are also fortified with iron. This form of iron is also better absorbed with
vitamin C.
4. Supplemental iron pills can also be taken. Vitamin C also helps the absorption of this
form of iron. Adolescents under 12 and all males should take 60 mg of elemental iron
daily, while females over 12 should take 120 mg elemental iron daily. Avoid taking the
pills within one hour of calcium supplements, dairy products, coffee, tea, and high fiber
foods; as these foods decrease iron absorption.
5. But these pills have many side effects that make it hard for some adolescents to take.
The slow release iron supplement has less side effects. Or smaller doses can be taken
more frequently throughout the day.
6. When diet and oral pills don’t work, iron can be given by infusion directly into the
blood. This is done slowly in an infusion center similar to how chemotherapy is given.

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1. Teenagers have similar risk factors and nutritional interventions for
hypertension as adult.

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1. Blood pressure will vary by age, sex, and height. Since these things are changing rapidly
during adolescence special charts are used to compare your patients blood pressure
with these charts. Thus diagnoses are based on percentiles of height against normal.

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1. Here is an example of a blood pressure chart.
2. The percentiles along the top are for the child’s height that were calculated from the
growth charts.
3. Then match the child’s height percentile with their age to find the number on the chart
that represents the 90th and 95th percentiles for blood pressure.

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1. An 11 year old girl at the 25% percentile of height has a BP of 120/80. Is this
normotensive or hypertensive?

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1. First find 25th percentile for girls on the top.
2. Then move down the chart to 11 years old. You see that 116 is in the 90th percentile
and 119 is the 95th percentile for systolic & 75 is the 90th and 79 is the 95th percentile.
3. Then you compare her number to these reference value. Both 120 and 80 are above
the 95th percentile for her age and height, thus she is hypertensive.
4. Thus blood pressure numbers that may be normal in an adult, may not be normal in a
child.

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1. Here are the criteria for diagnosing hyperlipidemia. Cholesterol levels
are lower than recommendations in adults.
2. Teenagers have similar risk factors for hyperlipidemia as adult.
3. Note that total and LDL cholesterol drops during puberty. Thus,
screening should occur before (~ age 10) and/or after (> age 17)
puberty.
4. Nutritional interventions depend on the extent of altered lipids and
which ones as listed in the CHILD 1/2 guidelines discussed in Lecture
10, Slide 38 on Toddlers. The “Dietary Approaches to stop
hypertension” (DASH) diet is also helpful in adolescents as it is in
adults. This diet is low in sodium, fat and sugars and high in
vegetables, fruits, whole grains, and low fat dairy. See Table 15.10 for
more details.
5. Teens with hypertension should limit eating at fast food restaurants
and/or make healthier choices, not skip breakfast, and consume
family meals.

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1. The general Dietary Guidelines are useful for children over 2 with normal lipid levels
and low risk factors.
2. These are the recommendations to prevent CVD later in life for children with risk
factors.
3. Note that limiting dietary cholesterol to a specific level was removed from the 2015
dietary requirements since we now know that dietary cholesterol intake plays less of a
role in blood levels than dietary fat and genetics, which alters how much cholesterol
your body makes. However, these recommendations were set by a different group of
experts in 2011 and have not yet been updated.

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1. Remember that insulin is required to lower blood glucose by allowing glucose to enter
cells. Insulin also signals the storage of extra glucose as glycogen and fat.
2. Also remember that type 1 diabetes is an autoimmune disease where the pancreas is
damaged and cannot produce insulin. These children require insulin to be injected such
that glucose can enter the cells. Type 2 diabetes is due to insulin resistance, which is
usually associated with obesity. Although there are a few other forms of type 2 where
obesity is not seen. This includes Maturity onset diabetes of the young (MODY). This is
caused my mutations in the genes involved in glucose metabolism in the pancreases.
These children cannot secrete insulin in response to a glucose signal.
3. Type 1 diabetes is much more common in children than type 2, especially those under
10.
4. Nutritional interventions are different for type 1 and 2. For type 1 it is all about
matching the amount and timing of food with the amount and timing of insulin. When
there is a mismatch than blood glucose levels can either be too high or too low.
Exercise allows glucose to enter the muscle cells in the absence of insulin. So the
amount and timing of exercise needs to also be factored in, otherwise a type 1 diabetic
could get hypoglycemia during exercise. I went to a diabetes camp during my dietetic
internship and found it to be very fun and rewarding. The children see that they are not
alone. They learn lots of tricks and skills from each other as well as from the education
that myself and the other councilors were providing.
5. Nutrition interventions for type 2 diabetes focus on decreasing obesity to improve
insulin sensitivity.

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1. Similar to during childhood, each condition is unique.
2. Some conditions require more energy, such as: chronic inflammatory bowel disease and
cystic fibrosis. But other disease require less energy, such as a teenager with cerebral
palsy who is confined to a wheelchair.
3. Many of the medications can impact nutrient metabolism and needs.
4. The assessment, intervention, and monitoring of nutrition is similar as during
childhood. But you need to remember that adolescents need to become more
independent and will need to be more engaged in the process.

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1. There is a continuum of eating disorders. All of these conditions are
unhealthy and should be discouraged. Plus, the more mild
dissatisfaction with ones body can lead to the more serious conditions
if left unchecked. Long term healthy lifestyles should be promoted
over short term dieting.
2. When girls first gain weight around menarche is when they begin to
be dissatisfied with their bodies. Some of these girls are not
overweight. Shortly after this period of weight gain is when binge
eating and/or purging was seen.
3. Interventions need to include having the adolescent accept their body.
An overweight teen should not be striving to look like a thin
supermodel. This move away from thin as normal is seen in some
media campaigns, such as dove soap.
4. https://www.nationaleatingdisorders.org/what-are-eating-disorders
5. https://www.nationaleatingdisorders.org/warning-signs-and-
symptoms
6. https://www.nationaleatingdisorders.org/risk-factors

7. https://www.eatingdisorderhope.com/information/eating-disorder
(demi lavato)

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1. While only 0.2-1% of adolescent females have anorexia nervosa, it is the most severe. It
is hard to fully recover from this mental illness, but the earlier it is diagnosed and
treatment is started the more likely the teen will recover, or at least manage the
disease.
2. The main factor that distinguishes anorexia from other eating disorders is the refusal to
maintain weight above the minimum weight for age and height.
3. The teens have an intense fear of gaining weight, distorted body image, and
amenorrhea.
4. There are two types depending on whether the teen just eats less (restrictive) or binges
and purges.

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1. This is another serious mental illness in that these periods of binging are uncontrolled.
It is also hard to fully recover from this mental illness, but the earlier it is diagnosed and
treatment is started the more likely the teen will recover. If the teen also has other
psychological conditions, such as borderline personality disorder, anxiety, or alcohol
abuse than treatment is less successful.
2. These teens can be of any weight. (underweight, overweight, or normal weight).

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1. These teens are usually overweight.
2. The main unique feature of this disorder is that these teens eating is out of their
control, as indicated by 3 of the listed criteria and they do NOT have compensatory
behaviors.
3. About half of the teens have binge-eating disorder before they begin to diet. However
teens that dieted first likely experienced sexual abuse or other stressful situations and
are trying to regain control. They have control during the dieting, but lack of control
during the binge eating. Not all teens that binge eat also diet, which then leads to
obesity.

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1. Each adolescent with an eating disorder will have a different cause. Understanding the
cause of the problem is the first step to treating it.
2. https://www.nationaleatingdisorders.org/risk-factors

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1. There are many warning signs of an eating disorder that need to be watched out for
when counseling teenagers.

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1. This video highlights the importance of saying the right thing.
2. https://www.nationaleatingdisorders.org/treatment-providers

3. https://www.nationaleatingdisorders.org/learn/help/caregivers

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1. Several different disciplines are needed for successful treatments, thus a team
approach is used.
2. The type of treatment that is required depends of the severity of the condition. Table
15.16 lists the criteria for being admitted to an inpatient facility.

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1. Both physical and psychological issues need to be addressed to successfully treat eating
disorders.

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1. The ultimate goal of nutritional care is to help the teen normalize their eating patterns
in a way that they will feel confortable doing when they have finished their treatment.
2. This is challenging as these adolescents may be in denial or not motivated to change.

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1. Since the success of treatment is low, it is best to prevent these disorders from
developing in the first place.
2. The reason that you would include all adolescents is that it is hard to really target those
that are at risk and may miss people when doing targeted programs. Although the
targeted programs are more successful because they can be more in depth.
3. There are some factors that make the prevention more successful, such as being
delivered by a trained professional and using interactive learning.
4. The key to choosing the best topics is to focus on modifiable risk factors that everyone
will feel comfortable discussing in the setting of the intervention. For example,
discussions about why the media’s portrayal of a thin model is not what we all need to
strive to look like.

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