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Adolescent Nutrition Contradiction in Terms? by Bill Cross and Belinda Brown, Registered Nurses At 9:45 AM a seventh-grader - we’ll call him "Jason" - comes into our office at Ashland Middle School complaining of a headache. We ask Jason a few quick questions, including what he ate for breakfast. "Nothing," he replies, "my head just hurts." We ask what he’s had to drink today. "Nothing," he repeats, but this time with a puzzled look — like he’s wondering if we’re hard of hearing or maybe just slept through anatomy class during nursing school (he came in about his head, after all, and we keep grilling him about his stomach). Then we rock Jason’s world by suggesting that his head pain might be related to not eating or drinking. We give him a minute to grapple with this apparent anatomical paradox (could the head bone actually be connected to the stomach bone?) and then recommend a quick trip to the cafeteria for a healthy snack and some water. Jason’s headache magically disappears. At 12:30 an eight-grader - "Jenny" - comes in clutching her stomach; "I feel like barfing," she moans. We ask a few questions, including what she’s had to eat and drink. "Some Cheetos and a frappucino for breakfast," she whimpers, "and two gummy worms for lunch." Jenny is shocked when we suggest that her stomachache might be related to what she did — and did not — eat. Jenny gets a quick refresher course in basic nutrition, and then a "meals-on-wheels" visit from Mom, who brings in a sensible lunch. W e see it every school day. As Registered Nurses at Ashland Middle School we routinely comfort, counsel and cajole students who are suffering the side effects of lousy nutrition. And as the parents of middle schoolers ourselves, we recognize the enormous challenge of getting adolescents to eat a healthy, balanced diet. We know that "adolescent nutrition" sometimes seems like the ultimate oxymoron. Adolescent Malnutrition: Shocking Shortcomings in the Land of Plenty The evidence is undeniable: the average American adolescent is severely malnourished. Not undernourished, mind you, but improperly nourished. Consider these statistics: According to the US Department of Agriculture (USDA), less than 15% of U.S. school children eat the recommended 2-4 daily servings of fruit, and fewer than 20% get the recommended 3-5 servings of vegetables. A recent study in the Journal of the American Medical Association reports that from 1986 to 1998 the percentage of American children who are overweight roughly doubled. According to Oregon’s 1999 Youth Risk Behavior Survey, only 38% of Oregon high school students report eating breakfast every day, while 30% say they skip the meal at least three times a week. The same study found that just 8% of Oregon’s high schoolers meet the minimum recommendation for daily servings of fruits and vegetables. Why are American kids eating so poorly? The list of suspects is enormous: busy schedules tempt teens to skip breakfast; families eat together less often, limiting chances for parental oversight and involvement; junk foods and high-calorie, high-fat snacks are easily available and heavily advertised; sodas are now the drink of choice for many teens, shoving aside healthier, nutrient-rich drinks like milk or limited quantities of fruit juice. The Consequences: Paying Now and Paying Later The consequences of poor nutrition early in life can be devastating. Eating patterns established in adolescence are tough to change. For example, those who become overweight as teens are much more likely to be obese as adults. And obesity increases the risk for a host of illnesses, including heart disease, high blood pressure and diabetes. Many of these diseases manifest themselves later in life, but some won’t wait that long: for example, researchers have noted an alarming increase in Type II diabetes among adolescents. Even teens who avoid obesity may be eating their way toward serious adult illnesses. High-fat diets increase cholesterol levels, which in turn can trigger the development of fatty plaques on blood vessel walls. Even teenagers aren’t immune to this process, and may already be developing deposits that could eventually trigger heart attacks or strokes in adulthood. Also, teens who don’t get enough fruits or vegetables may be increasing their risk of certain cancers. Another chronic illness that can begin with poor teenage nutrition is osteoporosis, or thinning of the bones. Low calcium intake during adolescence hampers the growth of sturdy bones, yet according to the USDA a mere 19% of girls ages 9-19 get the Recommended Daily Allowance (RDA) of calcium. Those who fail to develop sturdy bones early in life may pay a terrible price in later adulthood, when decreases in bone mass — especially among females - can lead to fractures. And even teenagers can suffer such fractures: one study notes a strong association between soda consumption and broken bones among teenagers. Some poor nutrition choices carry immediate consequences. Perhaps the most obvious is dehydration. At Ashland Middle School we see a remarkable number of students who simply forget to drink water. The result is dried-out teenagers who get frequent headaches and dizzy spells, and may be more prone to bladder infections and kidney stones. Caffeinated sodas compound the problem, since caffeine is a diuretic that further dehydrates the body. And strange but true, students often fail to eat. Recently we conducted an informal survey and found that less than half of the students who come to our office for any reason have eaten breakfast. And a startling number fail to eat lunch as well. Some kids pay for their indiscretion with headaches and stomach pains, but few make the connection to diet until it’s pointed out to them. Failing to eat and drink a balanced, nutritional diet can lead to all sorts of problems at school. Students lose class time and sometimes have to go home due to preventable headaches and stomachaches. They may have trouble focusing in class; several studies suggest that poor nutrition can impair learning and retention. They may have weakened immune systems, leading to more absences and slower recovery from illness or injury. We’ve even seen students pass out on the sports field due to simple dehydration from not drinking water. Our colleague Judy Blickenstaff, Family Nurse Practitioner (FNP) at the Ashland High School Health Center, notes that some students skip meals in an attempt to lose weight - but ironically the practice may have the opposite effect. "Skipping meals often leads to obesity," says Blickenstaff. "Your body adjusts to sporadic food intake by lowering its Basal Metabolic Rate (BMR), which means you burn fewer calories, and you end up making yourself SO hungry that you make hasty, poor food choices when you finally do eat." Note: There’s a big difference between forgetting to eat, or unhealthy eating, and a true eating disorder. See the sidebar for more information. What’s a Parent to Do? The answer seems obvious: feed and water your children! Reality, of course, is a bit more complicated. Fluids: Many adolescents are finding out the hard way that, to rephrase an old adage, "You are what you drink." As school health professionals the biggest problems we see with fluids are: 1) failure to drink water, and 2) overconsumption of sodas. A lot of kids think that anything worth drinking - including water — has to come from a bottle or can. Our advice on water is simple: do whatever it takes to get them to drink it. Buy them bottled water or simply refill water bottles at home. Whatever you do, make it as appetizing and "cool" as possible. Ask them what "kind" of water they prefer. Generally speaking, you can’t rely on them using drinking fountains at school; although some kids do, many think they’re as unnecessary as showers in the locker room. Carbonated sodas are a critical issue. One of the biggest single contributors to poor teenage nutrition is the displacement of water, milk and juice by this "liquid candy." According to a study in the Archives of Pediatrics and Adolescent Medicine, from the late 1970s to the mid-1990s milk consumption among adolescents fell 25-30%. Meanwhile, soda consumption mushroomed 41% from the late 80s to the mid-90s. Those statistics are particularly troubling when you consider that milk and juice are among American teens’ top sources of vitamins A, C, D and the B vitamins, as well as calcium, magnesium and phosphorus. Researchers concluded that simply substituting one glass of milk or juice for a glass of soda every day could reap major nutritional benefits. Meals: By now one thing should be obvious: too many kids are skipping breakfast, and we want to make sure your kids eat this vital meal! As Judy Blickenstaff says, "Autos don’t run on empty - why should we?" A first step could be to sit down with your teen and ask what they’d be willing to eat in the morning. Dialogue and teamwork usually work better than nagging or giving orders. Try to get your teenager to participate and "buy into" a solution. Quick breakfast ideas include smoothies, granola bars, leftover dinner, or just a banana and a glass of nonfat milk. Steer clear of high-sugar items, which can induce a "sugar slump" an hour or two after eating. If you can’t get kids to sit down to breakfast, give them something they can walk out the door with — a piece of fruit or a nutrition bar. Alternatively, sign your child up for school breakfast (check with your school for availability). The ideal, if you can manage it, is to eat breakfast with your kids. As parents, we sometimes think that by age 12 or 13 kids no longer value our input (and kids often do nothing to discourage this impression!). But adolescents are still learning from parents — especially by example. If they see you eating breakfast, they may pick up the message that you consider it important. It takes more time and effort ... but it may save time in the long run if it prevents a mid-day call to pick up your child from school when they get sidelined by a pounding headache brought on by meal-skipping. Once kids get to school, it gets harder for parents to monitor and influence food choices. One simple approach is to pack along a mid-morning snack. Many students need a boost between breakfast and lunch, and this is a great time for parents to sneak in one of those recommended daily servings of fruit. For lunch, a key goal is to squeeze in some kind of vegetable - but remember: potato chips and french fries don’t count! Dinner is typically the healthiest meal of the day for adolescents (often with the day’s only vegetable). Ideally, this is a meal shared with family. Not only do kids tend to eat better foods with family, but it gives parents and kids an important chance to talk. Looking for a Few Good Nutrients: Raising healthy adolescents is a bit like growing good tomatoes: both need plenty of clean water and the right nutrients. Let’s look at three key vitamins and minerals. Iron: This mineral is essential for blood cells to carry oxygen from the lungs to body tissues. Adolescent girls in particular may be iron deficient due to inadequate intake and menstrual losses. Iron deficiency — easily detected by a fingerstick blood test — can lead to anemia and other problems. Recommended daily iron intake is 18 mg/day. Prime sources include fortified breakfast cereals and breads, dried beans, soybeans and tofu, peanuts, spinach, mustard greens, red meat and poultry, raisins and some shellfish. Foods high in vitamin C help the body absorb iron. Calcium: This mineral is essential for strong bones, especially among females. Recommended intake is 1200-1300 mg/day, and if girls don’t drink milk, they seldom get enough. Good sources include milk, yogurt, cheese, broccoli, almonds, collard and mustard greens, and some fruits. Supplements may be useful if dietary sources aren’t meeting the need. Folic Acid: This B-vitamin is essential for proper brain development in fetuses during the first weeks of life - often before a woman knows she is pregnant. Folic acid deficiency is a leading cause of birth defects. Most health professionals now recommend that all girls and women who are menstruating get in the habit of eating foods high in folic acid - and taking supplements if necessary - so that if and when they do eventually become pregnant, folic acid will be "on board." Recommended intake is 400 micrograms (mcg) daily. Sources include fortified cereals and breads, leafy green vegetables, beans, peas, and certain juices including orange, grapefruit and pineapple. Calories and Activity: America’s rate of adolescent obesity is ... well ... ballooning. It’s a national problem with lifelong implications, and researchers have pointed the finger at everything from soda pop to french fries to Nintendo® games. Whatever the cause, the basic goal is fairly simple: get kids to consume an appropriate number of healthy calories to match a moderate to vigorous level of physical activity. Sounds straightforward ... but obviously it’s not. At the middle school level we’re seeing more and more overweight, inactive kids. And as Blickenstaff notes, "Once they get into high school and get a car, they never walk again!" As with other aspects of nutrition, parents teach volumes by example; if you take exercise seriously, your child is more likely to follow suit. And again, cooperative dialogue and brainstorming are more likely to bring change than directing and dictating. As school nurses we are here to help with information, advice, educational materials, ideas and support. Other resources include dieticians, healthcare providers, and a host of internet sites. The challenge of achieving good adolescent nutrition is enormous, but so are the rewards. To parents and kids we say: hang in there, work together and remember that, in the immortal words of one school nurse, "The pediatrician of choice is not Dr. Pepper." Belinda Brown has been an RN for 17 years, including work in acute care, home care, hospice and special education. She has been at Ashland Middle School for four years, and recently expanded her practice to Ashland’s elementary schools. Bill Cross is an RN and a free-lance outdoor writer. He worked in emergency nursing before coming to Ashland Middle School. "Failing to eat and drink a balanced, nutritional diet can lead to all sorts of problems at school."