This chapter will address the following American College of Graduate Medical Education competencies: interpersonal and communication skills, professionalism, and systems-based practice.

Interpersonal and Communication Skills: Skills that enhance effective exchange of information and collaboration with teens and families are particularly important in adolescence as teens are increasing their decision making. This chapter will help pediatric health care providers enhance their communication skills around making healthy lifestyle changes with adolescents and their families.

Professionalism: This chapter will help pediatric health care providers provide teen care that is individualized, evidence based, compassionate, and family centered by focusing on commitment to professional responsibilities, ethical principles, sensitivity to diversity, and values of respect, compassion, and kindness.

Systems-Based Practice: This chapter will help pediatric health care providers caring for adolescents demonstrate an awareness of the larger system of health care delivery and ability to interact with the system to optimize teen outcomes.

The onset of puberty and emergence into adolescence presents increased nutrition risk due to dramatic changes in physical, cognitive, and emotional development. There is increased demand for most nutrients due to pronounced linear growth and increases in muscle mass, vascular system, adipose layers, and bone density.¹ At the same time, lifestyle changes—increased reliance on peers, greater independence in food choice, availability, and increased activity—add a level of complexity in helping an adolescent meet his or her needs.²

In an ideal situation, the teen will be able to gradually emancipate from the feeding relationship that has been developing since infancy and begin to meet his or her nutrition needs independently. That said, special situations in which the teen may need some additional guidance and support include vigorous sports and physical training, female athlete triad, excessive dieting, eating disorders, obesity, pregnancy, drug and alcohol use, lifestyle diets (eg, vegetarian), and chronic illness.^1,3

Primary risks of undernutrition

The special situations mentioned above often include an inadequate intake of nutrients, including energy (calories). The risks associated with undernutrition include delayed puberty, amenorrhea, decreased bone mineralization, bradycardia or tachycardia, growth stunting, iron deficiency, and dehydration.^1,3

Fad diets and unhealthy weight control practices

In order to lose or control weight, adolescents may engage in unhealthy weight control practices such as dieting, food restriction, skipping meals, using diet pills, and vomiting.¹ It is important to keep these tendencies in mind when working with adolescents around weight management. Studies show that adolescents who diet or use unhealthy weight control practices are at increased risk of obesity later in life.¹ The use of fad diets should also be discouraged because weight lost using unsustainable methods is regained and the adolescent will not have learned any skills to sustain and promote health over the long term. Instead of focusing on dieting and weight loss, studies suggest it is more effective to focus on promoting positive body image, decreasing unhealthy weight control behaviors, and limiting negative weight talk to help promote healthy weight during adolescence.^4,5

Energy (calorie) needs

It is crucial to note that energy and protein needs correlate more with the growth spurt than with chronological age. Energy needs vary between individuals due to differences in growth velocity, age at puberty, proportion of lean body mass to adipose tissue, and physical activity.

Estimates of needs can be reassessed when compared to nutrient intake, weight gain, and growth over a 1- to 3-month time period.²

In adolescent boys, nutritional needs accelerate with onset of puberty (ie, heightened linear growth and weight gain) due to 2-fold increase in muscle mass. Peak velocity of linear growth occurs later in puberty in boys than in girls (14.4 years on average in boys).^1,2

In adolescent girls, peak velocity of linear growth takes place approximately 6 to 12 months prior to menarche (average age of menarche 12.5 years).

Adequate energy intake and growth are essential to support normal menstruation, and will support development of peak bone mass. Weight gain slows around the time of menarche, but will continue into late adolescence. By 18 years of age, more than 90% of adult skeletal mass has been accrued.²

Calculating energy needs

The following information provides a framework to estimate energy or calorie needs for an individual:

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  Energy goal for weight gain—basal metabolic rate (BMR) (based on ideal body weight [IBW] for height) × 1.5-1.7 kcal. As a starting place, IBW can be estimated with a weight at which the body mass index (BMI) is 50th percentile for age (2-20 years).⁶

  
  
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  Energy goal for weight maintenance or loss—BMR (based on IBW for height) × 1.3-1.5 kcal.⁶

Protein needs

Dietary reference intake (DRI) for age allows for nutrient needs during the most accelerated adolescent growth period (ie, no need to adjust for growth and age of maturation) (see Table 5-4 in Chapter 5).⁷

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  Protein needs for weight gain are approximately 20% of total energy, which is generally achieved by eating normal meals and snacks at estimated goal energy level.⁷

  
  
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  Protein needs for competitive athletes to support tissue repair and red blood cell synthesis during extensive muscle building and strength training may be as high as 150% to 200% × DRI or 1.2 to 1.5 g/kg.⁸

Vitamins and minerals

The DRI for age allows for nutrient needs during the most accelerated adolescent growth period (ie, no need to adjust for growth and age of maturation).⁹ Typical adolescent eating patterns or chronic disease can set the teen up for significant nutrient concerns that are discussed next.

Iron deficiency

Iron deficiency continues to be a key nutrient deficiency for both genders, all races, and all socioeconomic levels.¹⁰ In fact, food insecurity is associated with iron-deficiency anemia in US adolescents.¹¹ Iron is required for adequate developmental growth and immune function. For a diagnosed deficiency, it is important to conduct a thorough history and consider

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  assessment of and education about bioavailability of iron sources and vitamin C intake,³

  
  
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  assessment of and education about resources to improve food insecurity.¹¹

Calcium, vitamin D deficiency

With increased rate of growth, adolescents need to ensure adequate calcium and vitamin D intake. A good history of dietary intake and supplements should yield adequate information to provide education. Also, a current knowledge of recommendations is required—1300 mg/day for calcium and 600 IU/day of vitamin D.¹² Adolescents on chronic steroid treatment or with secondary amenorrhea (due to energy deficit) are at increased risk of osteopenia and osteoporosis and may require supplementation.^3,13

Fluid

Fluid needs can be estimated according to this table and then be increased as needed:

Exercise

Physically untrained teens are at risk for dehydration and heat stroke and require more fluids to maintain hydration and temperature regulation than physically trained teens.¹⁵ Untrained individuals should have unlimited access to fluids during exercise to improve hydration and temperature regulation. Even a fluid loss equivalent to a 2% decrease in body weight may impede strength and stamina.⁸

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  Exercise less than 60 minutes: Water is recommended for fluid replacement.¹⁵

  
  
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  Exercise more than 60 minutes: Sports drinks containing 6% to 8% carbohydrate kilocalories (50-80 kcal/8 oz) recommended to supply energy and electrolyte replacement for optimal fluid absorption (> 10% carbohydrate kcal slows fluid absorption; < 5% carbohydrate kcal supplies inadequate energy).¹⁵

Assessment

An adolescent should have access to a registered dietitian (RD) or registered dietitian nutritionist (RDN) with experience in working with teens, so that his or her complex needs can be thoroughly assessed and then treated with in-depth food and nutrition expertise. Ideally, the RD or RDN will be a member of an interdisciplinary team including medical providers and providers in the psychosocial realms. A team may be better equipped to work in the demanding area of adolescent health and in fact, each team member can support the messages and guidance by others, thus reinforcing recommendations.¹⁶

Physical parameters

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  Weight, height, and BMI

  
  
  
  
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    Plot current data on gender-appropriate Centers for Disease Control and Prevention (CDC) chart (2-20 years).

    
    
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    Compare with weight and height history to determine change in weight and growth velocity over the past 3 to 12 months.

  
  
  
  
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  IBW—estimate based on available growth history; generally between the 25th and 75th percentile for BMI for age

  
  
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  Interpretation and goals

  
  
  
  
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    General weight goal is 90% to 110% of IBW.

    
    
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    Rapid or chronic weight loss to less than or equal to 85% to 90% IBW increases risk of delayed puberty or amenorrhea; sustained weight more than 90% IBW for several months is goal for menses to resume.

  
  
  
  
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  Monitoring weight and height

  
  
  
  
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    Inpatient

    
    
    
    
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      Weight—1 to 3 times per week depending on acuity of condition or as otherwise determined by specific disease state

      
      
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      Height—monthly or as otherwise determined by specific disease state

    
    
    
    
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    Outpatient

    
    
    
    
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      Weight—weekly to biweekly until healthy habits are established as a stable lifestyle, and oral intake and weight goals are demonstrated; then monthly to every 2 to 6 months as needed to demonstrate compliance with goals. Attenuation of rate of weight gain is an appropriate initial goal as health-supporting behaviors begin. Then, 0.5 to 1 lb loss per week is appropriate with as high as up to 2 lb per week.¹⁷ With any loss, providers should be evaluating for high-risk behaviors such as over-restriction of calories or nutrients.

      
      
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      Height—monthly to demonstrate compliance with weight goals; then every 2 to 6 months as needed with weight checks.

    
    

  
  
  
  
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  Arm muscles and fat stores measured by an RD

  
  
  
  
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    Technique should be standardized and consistent using a good quality set of skinfold calipers.¹⁸

    
    
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    General goal is 25th to 75th percentile arm muscle area and arm fat area for age and gender.¹⁹

    
    
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    Assess every 6 to 8 weeks as needed to demonstrate body composition changes.

    
    
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    Can be a very helpful educational tool as the amount of muscle, its purpose, and its relationship to body weight is discussed and the teen is reassured that he or she is not “100% fat.”