Adolescent eating habits Authors Debby Demory-Luce, PhD, RD, LD Kathleen J Motil, MD, PhD Section Editor Amy

B Middleman, MD, MPH, MS Ed Deputy Editor Alison G Hoppin, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Apr 2013. | This topic last updated: Sep 18, 2012. INTRODUCTION Nutritional needs during adolescence are increased because of the increased growth rate and changes in body composition associated with puberty [1,2]. The dramatic increase in energy and nutrient requirements coincides with other factors that may affect adolescents' food choices and nutrient intake, and thus nutritional status. These factors, including the quest for independence and acceptance by peers, increased mobility, greater time spent at school and/or work activities, and preoccupation with self-image, contribute to the erratic and unhealthy eating behaviors that are common during adolescence [1,3]. Sound nutrition can play a role in the prevention of several chronic diseases, including obesity, coronary heart disease, certain types of cancer, stroke, and type 2 diabetes [4-12]. For this reason, nutrition was a priority area for the Healthy People 2010, and remains an important objective for Healthy People 2020 [13]. To help prevent diet-related chronic diseases, researchers have proposed that healthy eating behaviors should be established in childhood and maintained during adolescence (table 1) [14-17]. (See "Healthy diet in adults".) National and population-based surveys have found that adolescents often fail to meet dietary recommendations for overall nutritional status and for specific nutrient intakes [18-21]. Many adolescents receive a higher proportion of energy from fat and/or added sugar and have a lower intake of a vitamin A, folic acid, fiber, iron, calcium, and zinc than is recommended [18,22-27]. The low intake of iron and calcium among adolescent girls is of particular concern. Iron deficiency can impair cognitive function and physical performance, and inadequate calcium intake may increase fracture risk during adolescence and the risk of developing osteoporosis in later life [18,28-33]. (See "Iron requirements and iron deficiency in adolescents" and "Calcium requirements in adolescents".) This topic review discusses characteristic adolescent eating habits, including skipping meals, fast food consumption, frequent snacking, and dieting behaviors [1,34-36]. The nutritional requirements for adolescents are discussed separately. (See "Dietary energy requirements in adolescents".) SKIPPING MEALS Adolescents may skip meals because of irregular schedules [37]. Breakfast and lunch are the meals most often missed, but social, school, and work activities can cause evening meals to be missed as well [1,38,39]. On any given day, 12 to 50 percent of adolescents skip breakfast; older adolescents (those age 15 to 18 years) are twice as likely to skip breakfast as are younger adolescents, and girls are more likely to do so than are boys (35 versus 25 percent, in one study) [1,38,40-42]. More than one-half of the adolescents participating in the National Adolescent School Health Survey reported they ate breakfast less than twice per week [34]. Reasons for skipping breakfast include lack of time, early school activities, or a poor appetite first thing in the morning [1,43]. The omission of breakfast can affect school performance and the overall quality of the diet [44-47]. In one cross-sectional and longitudinal study of school breakfast programs, students with greater participation in the breakfast program had greater increases in math grades, decreases in child and

teacher ratings of psychosocial problems, and decreases in absence and tardiness than did children with less participation [48]. In another large-scale survey of school children from nine states, hungry children and children at risk for hunger were more likely to have impaired function, hyperactivity, absenteeism, and tardiness than were not-hungry children [49]. Total nutrient intakes are lower among adolescents who skip breakfast as compared to those who consume breakfast [1,47,50]. Adolescent breakfast consumers have a higher intake of calories, fiber, vitamins A, B6, and B12, iron, and calcium and better overall eating habits than do adolescents who skip breakfast [39-41,46,51,52]. When breakfast is consumed, it contributes approximately one-fourth (21 to 26 percent) of total daily energy intake [41,53,54]. The foods that typically are skipped with breakfast include fruits, breads, and calcium- and iron-rich foods (milk and iron-fortified cereals, respectively) [20,39,40,46,55,56]. Adolescents who skip breakfast tend not to compensate for these losses at other meals [44,55,57]. Adolescents' busy lifestyles often conflict with family mealtimes [1,58,59]. There is a decline in family meal frequency during adolescence, and family meals are associated with higher diet quality [20,36,56,60]. One study of 16,000 children aged 9 to 14 years demonstrates that children who eat meals with their families most or all of the time have healthier diets than do those who rarely or never do [61]. Compared to those who rarely eat with their families, they consume less fried food and soft drinks and more fruits, vegetables, and whole grains [61]. A five-year longitudinal study with 1700 adolescents found that family meal frequency during adolescence predicts higher intakes of fruits, dark-green and orange vegetables, and lower intakes of soft drinks during early adulthood [20]. Adolescents, particularly females, may use skipping meals as a strategy for weight control [35,62,63]. However, the calories that are "saved" are often made up through heavy snacking on nutrient-poor foods, or by overeating at the next meal [64]. This pattern tends to impair nutrition because highfat/energy-dense snack foods rarely compensate for the nutritional value of the meals that are skipped [38]. Moreover, skipping meals does not seem to improve weight control, as illustrated by the following studies: A 1991 United States Department of Agriculture (USDA) Survey showed that adolescents who had a consistent meal pattern (at least two meals per day), were leaner than those who had an inconsistent meal pattern (one meal or snacks only per day) [3]. A Dutch study found that adolescents who ate breakfast on a daily basis were less likely to be overweight than those who ate breakfast irregularly or never [65]. A cohort study examined 2379 adolescent girls aged 9 to 10 years at baseline, and followed them until 19 years of age [39,66]. Among girls with high BMI at baseline, those who ate breakfast more often had a lower BMI at the end of the study compared with those who ate breakfast less often. Similarly, in the full population, lower snack and eating frequencies at baseline were associated with greater gain adiposity during the 10-year follow-up period [67]. A prospective study followed 9919 adolescents participating in the National Longitudinal Study of Adolescent Health during the five-year transition period between adolescence and young adulthood [68]. This study found that breakfast skipping was associated with weight gain during this time period. A 1999 to 2006 National Health and Nutrition Examination Survey (NHANES) found that adolescents who skipped breakfast had a higher BMI compared with those who consumed breakfast [50].

Possible explanations for this finding include [67]: Adolescents perceive that they are reducing energy intake by skipping meals when in fact they are not

Individuals with a propensity to gain weight are more likely to skip meals to compensate Skipping meals is a marker for other poor nutrition and physical activity habits [69,70]

In any case, it appears that meal skipping for weight control may result in an unhealthy diet and may cause unintended weight gain during adolescence [35,39,51,62,68,71]. (See 'Dieting' below.) Counseling Adolescents should be advised not to skip meals, particularly breakfast. Eating regular meals, using the Choose My Plate tool as a guide, can increase total nutrient intake as well as the mean number and amount of servings from food groups that typically are low in adolescents' diets (eg, iron- and calcium-rich foods and fruits and vegetables) [35,72,73]. (See 'Dietary balance' below.) Adolescents should be informed that skipping meals does not help with weight control, and indeed may promote weight gain, as discussed above. SNACKING Most adolescents snack [34,38,53,74,75]. After approximately 12 years of age, teenagers seldom conform to a regular pattern of three meals per day; more than one-half of teens admit to eating at least five times per day [35,38,42,75]. Snacks are a major source of energy and nutrients, providing nearly one-quarter to one-third of total energy intake for many adolescents [35,76]. Depending upon their timing and composition, between-meal snacks can contribute in negative or positive ways to the adolescent diet [77]. Poorly timed snacks that are high in calories and low in nutrients (ie, "junk food") may blunt the adolescent's mealtime appetite and replace nutritious foods that are needed for growth and development [1,34,35]. In particular, sugar-sweetened beverages often have a negative impact on diet quality [26] and also contribute to weight gain [78,79]. In a national survey in the United States, sugar-sweetened beverages or fruit juice comprised 10 to 15 percent of the calories consumed by children and adolescents [80]. In contrast, healthy snacks can help meet the increased energy and nutrient needs of adolescence [2]. Snacks that are nutrientdense (ie, have a ratio of nutrients to calories similar to that of meals) can help to fill the "nutritional gaps" (eg, fiber, vitamin A, calcium, and iron) that remain after traditional meals [1,4,35,81]. Television viewing is associated with increased snacking among children and adolescents [82]. In an analysis of food advertisements shown during television programs designed for children, more than 90 percent of the advertised foods were high in fat, sodium, or added sugars, or low in overall nutrients. The most commonly advertised food included ready-to-eat cereals and cereal bars, fast food, snack foods (chips, cookies, fruit rolls), and candy [83]. Exposure to advertising of poor-quality snack foods appears to be an important mechanism for the association between television viewing and obesity. (See "Definition; epidemiology; and etiology of obesity in children and adolescents", section on 'Environmental factors'.) Counseling Adolescents should be taught how to improve the overall quality of their diets with nutritious snacks [1,34]. Instead of selecting high-fat, high-sugar, nutrient-poor snacks such as candy, pie, cakes, cookies, and chips, adolescents should select foods that are lower in fat and more nutrient-dense, such as [84]: Fresh fruit or vegetables with low-fat yogurt dip Iron-fortified cereal and low-fat milk String cheese Cheese and crackers Low-fat frozen yogurt Calcium-fortified cereal bars and juices Vegetarian pizza

FAST FOODS As they become more independent, adolescents increasingly make their own decisions about what, when, where, and with whom to eat [5]. With busy after-school schedules, adolescents frequently eat away from home. Fast foods are popular choices because they are inexpensive, familiar, and available at almost any hour of the day or night and because many adolescents socialize with their peers at fast food establishments [34,85,86]. Individuals younger than 18 years of age account for more than 80 percent of fast-food restaurant visits [86,87]. The most popular food items consumed by adolescents at fast food establishments include french fries, sandwiches (especially hamburgers and cheeseburgers), pizza, and Mexican dishes (tacos and burritos) [88]. The most common beverage choices are carbonated soft drinks,coffee/tea, and milk (in that order) [88]. (See "Fast food for children and adolescents".) The impact of fast food on the diets of adolescents depends upon the frequency of visits to fast food restaurants and the food choices that are made, but fast food generally has adverse effects on diet quality [89-91]. Traditional fast foods are low in iron, calcium, vitamins A and C, fiber, and folic acid and high in energy, sodium, cholesterol, and total and saturated fat (table 2) [1,23,34,90-93]. Fat provides more than 50 percent of the calories in many fast food items [1,85]. In Project Eat (Eating Among Teens), the total energy intake of adolescents who reported eating at a fast food restaurant more than three times in the preceding week was almost 40 percent higher than those who did not. [85]. Increased fast food consumption was associated with greater intakes of soft drinks and lower intakes of fruits, vegetables, grains, and milk. Fast food consumption also has a modest association with overweight status among adults [94] and adolescent girls [95]. (See "Fast food for children and adolescents", section on 'Association with obesity'.) Counseling Fast foods are a way of life for many adolescents. It is important to teach adolescents how to make wise food choices at fast food restaurants. Many fast food restaurants offer lower fat and nutrient-dense food choices in addition to traditional selections, and a meal that provides important nutrients for adolescent growth and development can be ordered [96]. Healthier choices include salad bars, baked potatoes, steamed vegetables, low-fat frozen yogurt, and lower-fat sandwiches (table 3) [1,34]. (See "Fast food for children and adolescents".) In addition, because healthy snacks can compensate for nutrient deficiencies, adolescents should supplement fast foods with nutritious snacks, including calcium-rich foods and fresh fruits and vegetables [34,81,97]. DIETARY BALANCE The daily composition of a recommended diet is based upon the 2010 Dietary guidelines for Americans [24], which are taught by the USDA Choose my plate tool. Choose my plate replaced the Food Guide Pyramid in 2011 ( www.ChooseMyPlate.gov) [25]. The tool was developed to individualize dietary guidelines according to age, sex, and activity level; it replaces the previous pyramid-based model. Choose my plate focuses on five food groups (fruits, vegetables, grains, dairy, and protein) rather than the six groups outlined in the Food group pyramid previously used, and does not have a category for discretionary calories. The plate provides a visual tool for dietary balance; individuals are encouraged to cover half their plate with fruits and vegetables. Examples of recommendations for individuals at several different calorie levels are provided in the table (table 4). (See "Dietary history and recommended dietary intake in children", section on 'Dietary composition'.) Vegetables and fruits For an adolescent with low activity levels, the dietary recommendations translate to approximately 2.5 cups of vegetables and 1.5 cups of fruit for girls (1800 calorie diet), and 3 cups of vegetables and 2 cups of fruit for boys (2200 calorie diet). Actual consumption of fruits and vegetables is well below these targets. In a 2010 survey of high school students, the median consumption of fruits and vegetables was 1.2 times per day for both vegetables and fruits (100 percent fruit juice was included as a fruit) [98]. Consumption decreased

between the beginning and end of high school. Overall, about 30 percent of high school students consumed fruit less than once daily, and 30 percent consumed vegetables less than once daily. Low consumption of fruits and vegetables is associated with higher intakes of fast food. (See 'Fast foods' above.) Dairy The dietary guidelines outlined in Choose my plate also promote a high intake of dairy products (about 3 cups/day for adolescents); low-fat or fat-free products are recommended. The recommendations are consistent with current recommendations for intake of calcium, although actual intake is considerably lower among most adolescents in the United States. (See "Calcium requirements in adolescents" and "Calcium requirements in adolescents", section on 'Recommended intake'.) The recommended three servings of fortified dairy products provides about 350 International Units of Vitamin D [99], which is about half of the recommended daily intake for adolescents. In a study with 559 adolescents aged 14 to 18 years, 56 percent had insufficient levels of vitamin D [100]. Thus, intake of vitamin D fortified foods (breads, cereals, and juices), fatty fish (salmon, mackerel, sardines) and supplementation of vitamin D may be needed, particularly for adolescents who have less than the recommended three servings daily. (See "Vitamin D insufficiency and deficiency in children and adolescents", section on 'Recommendations for vitamin D intake'.) DIETING It is common for adolescents to be unhappy with and self-conscious about their changing bodies [101]. In many cultures, thinness, no matter how unrealistic, is perceived as the desired body shape, particularly for females. To avoid becoming overweight and to fit in, many adolescents attempt to lose weight by regulating their food intake [5,102]. In the discussion below, we use the term "dieting" to describe the manipulation of food intake and food choices that are specifically driven by weight concerns rather than health concerns. This type of dieting is distinct from efforts to adopt healthy eating and other lifestyle behaviors (ie, physical exercise) that are recommended to optimize nutrition and body weight as part of long-term health goals. Dieting is more common among female adolescents because females typically are more dissatisfied with their weight than are their male counterparts [35,62,103]. Unfortunately, many adolescent females perceive the normal pubertal weight gain as becoming "fat" and engage in dieting behaviors in an attempt to reverse or slow down the process [104]. Weight concerns and dieting are so common among female adolescents that they are considered to be normative [105]. Dieting and disordered eating behaviors in adolescents include [21,62,63,106-108]: Exclusion of specific foods or food groups Adopting reduced-energy diets or fad diets Skipping meals Binge eating Fasting Self-induced vomiting Using laxatives, diet pills, and diuretics Excessive exercising

Adolescents indicate the following reasons for dieting: feeling "too fat", teasing by peers, pressure from family members, advice of a coach or sports instructor, wanting to look better (ie, thin), and desire to improve health [108-111]. Prevalence A history of dieting can be obtained in approximately 40 to 70 percent of adolescents [21,63,112-115]. As indicated above, more females than males diet (45 versus 20 percent in one study) [62,108], and the gender difference increases significantly with age (56 percent of girls in grades 9 through 12 versus 36 percent of girls in grades five to eight) [62,108,113].

Of particular concern is the degree of dieting among adolescent females who are of normal weight. Many of these girls have dissatisfaction with their bodies that stems from unrealistic perceptions of a healthy body shape and/or body weight [62,114,116,117]. They perceive themselves to be fat although they are not. Self-perceived weight status is associated strongly with weight loss behaviors among adolescent females [116,118]. The frequency of dieting varies by region and by nation. In a 1997/98 World Health Organization report of 120,000 students aged 11, 13, and 15 years in 26 European countries, the United States, and Canada, dieting was most common among adolescents in the United States, Israel, and Austria [113]. The percentage of 11-, 13-, and 15-year-old girls and boys in the United States, Israel, and Austria who currently were dieting or thought they should be dieting in these three countries is outlined below: Among 11-year olds United States: 47 percent of girls, 34 percent of boys; Israel: 39 percent of girls, 27 percent of boys; Austria: 36 percent of girls, 29 percent of boys Among 13-year olds United States: 53 percent of girls, 33 percent of boys; Israel: 55 percent of girls, 26 percent of boys; Austria: 49 percent of girls, 30 percent of boys Among 15-year-olds United States: 62 percent of girls, 29 percent of boys; Israel: 57 percent of girls, 27 percent of boys; Austria: 53 percent of girls, 18 percent of boys

The observations that adolescents often perceive themselves to be overweight even when they are not, and that they frequently use unhealthy dieting behaviors when they try to lose weight were shown in several large population studies, described below. In a nationally representative survey of 6728 adolescents in grades 5 through 12 in the United States, 45 percent of girls reported dieting behaviors (36 percent and 56 percent of the girls in grades 5 through 8 and 9 through 12, respectively) [108]. Only 24 percent of the girls actually were overweight or obese (BMI 85th percentile). Twenty percent of boys reported they had dieted at some point (18 percent and 23 percent of boys in grades 5 through 8 and 9 through 12, respectively). Disordered eating behaviors (self-induced vomiting and binge eating) were reported by 13 percent of the girls and 7 percent of the boys. (See "Eating disorders: Epidemiology, pathogenesis, clinical features, and course of illness".) According to the 2011 Youth Risk Behavior Survey, a nationwide survey of high school students, 61 percent of females and 32 percent of males were attempting to lose weight [21]. Methods to lose or maintain weight included eating less food or foods low in fat (55 percent of females, 27 percent of males), fasting for 24 hours (17 percent of females, 7 percent of males), using diet pills, powders or liquids (6 percent of females, 4 percent of males), and vomiting or taking laxatives (6 percent of females, 3 percent of males). In addition, 35 percent of the female high school students thought they were slightly or very overweight when only 10 percent actually were (defined as a BMI 95th percentile). Overall, 29 percent of students reported daily vigorous physical activity, 32 percent attended physical education classes five days a week, and 32 percent watched three or more hours of television daily. Effects on nutrition Dieting behaviors can compromise intake of energy and nutrients that are essential for adolescents' growth and development. Adolescents diet mainly by restricting food, either by excluding foods or entire food groups that are perceived as "fattening" (eg, meats, eggs, and milk and dairy products) and/or by skipping meals [103,119]. (See 'Skipping meals' above.) The result is a diet that is low in several major nutrients that are already marginal in many adolescents' diets (eg, iron, calcium, and zinc) [31,72,120,121]. As an example, one study compared the diets of 16- to 17-year-old English girls who dieted to those who did not [122]. The mean energy intake of the dieters was less than that of the nondieters (1604

versus 2460kcal/day). Dieters had significantly lower intakes of breakfast cereal, milk, meat, and meat products. Twice as many dieters as nondieters failed to achieve recommended levels (dietary reference values for United Kingdom) for calcium, zinc, and selenium. Both dieters and non-dieters had low intakes of iron, but dieters' intakes were lower. Mean daily intakes of the various nutrients are listed below: Calcium 589 mg versus 856 mg among dieters and nondieters, respectively (United Kingdom reference nutrient intake [RNI] = 800 mg/day) Zinc 6.6 mg versus 9.1 mg among dieters and nondieters, respectively (RNI = 7.0) Selenium 45 mcg versus 62 mcg among dieters and nondieters, respectively (RNI = 60 mcg/day) Iron 12.1 mg versus 13.1 mg among dieters and nondieters, respectively (RNI = 14.8 mg/day) Riboflavin intake 1.2 mg versus 1.7 mg among dieters and nondieters, respectively (RNI = 1.1 mg/day)

Female adolescents may have difficulty obtaining the recommended 15 mg of iron per day from food sources if energy intake is low. In particular, reduced intake of animal foods high in iron such as meat and eggs can compromise iron intake [34]. In one study of 12- to 14-year-old British girls, the prevalence of iron-deficiency anemia associated with lower dietary intake of iron was greater among girls who had tried to lose weight than among those who had not (23 percent versus 7 percent, respectively) [123]. Dieting behaviors, particularly skipping meals, can reduce the opportunities to consume foods high in calcium. Milk and dairy products are a major source of calcium for adolescents (table 5) [33,124]. (See "Calcium requirements in adolescents".) Avoidance of meats, eggs, and dairy products also can result in inadequate zinc intake [125]. Other foods high in zinc include ready-to-eat cereals, legumes, wheat germ, and whole grains (table 6). (See "Zinc deficiency and supplementation in children and adolescents".) Adverse effects on health Long-term dieting may have adverse effects on an adolescent's health. Potential adverse effects include irritability, difficulty concentrating, sleep disturbance, muscle wasting, cardiac dysfunction, digestive tract disorders, menstrual irregularity, interruption in growth, delayed sexual maturation, and inadequate bone mass accumulation [126-128]. Adolescents who diet frequently are at increased risk for developing eating disorders such as anorexia nervosa and bulimia [120,129-132]. In one three-year prospective study of 1728 14- to 15year-old adolescents in Australia, girls who dieted at a moderate or severe level [133] were 5 and 18 times more likely to develop an eating disorder, respectively, than were girls who did not diet [130]. A longitudinal study of 2500 adolescents found that adolescent girls who dieted were at twice the risk for engaging in extreme weight-control behaviors (including vomiting or laxative use) and reporting an eating disorder five years later compared to nondieters [120]. Another study of 800 children and adolescents found a significant association between weight reduction efforts during adolescence and subsequent development of bulimia [134]. (See "Eating disorders: Epidemiology, pathogenesis, clinical features, and course of illness".) Lack of weight control Many behaviors used by adolescents in an attempt to lose weight may be ineffective in reducing weight. Paradoxically, they can lead to binge eating behaviors and ultimately to weight gain [67,69,104,132,135-137]. This was shown in an observational study of eating habits in 1902 adolescents who completed a survey about their eating habits at baseline and were followed for ten years [70]. Unhealthy dieting habits such as skipping meals, eating very little, and the use of food substitutes or diet pills were associated with substantially greater weight gain during the follow

up period even after adjustment for baseline weight status. The body mass index (BMI) increased by 4.63 kg/m2 among adolescents using these unhealthy dieting behaviors, as compared to a BMI increase of 2.29 kg/m2 among those who did not. The results suggest that weight reduction efforts reported by teenage girls are more likely to result in weight gain than in weight loss. In addition, repeated dieting is highly correlated with cycles of weight loss and gain (ie, "yo-yo" dieting), a risk factor for development of coronary heart disease [72,105]. Because of the dramatic increase in the proportion of obese adolescents in the United States between 1980 and 2005 (more than tripled from 5 to 18 percent) [138,139], dieting is a much debated issue [130,140,141]. Unless medically indicated and guided toward healthy eating behaviors, dieting can be unhealthy for a growing adolescent even if he or she is overweight [130,142,143]. Focusing on a well-balanced diet that includes a decrease in consumption of foods with high-energy density and increasing exercise may offer a safer alternative to food restriction for an adolescent who needs to lose weight [142,144-147]. Counseling Health care professionals play a role in educating adolescents about the normal changes in growth and development that occur during adolescence, and in helping adolescents understand that self-imposed dieting is neither healthy nor desirable for their growing bodies, and may actually increase body weight [106,109,110,148]. As part of the routine health maintenance examination, primary care providers should ask about body image and dieting patterns and/or use a validated written measure such as the Eating Attitudes Test (table 7). Counseling or referral to a dietitian is warranted if the adolescent is using unsound dieting or weight loss practices [72]. Referral for psychological or psychiatric evaluation is indicated if an eating disorder is suspected. (See "Eating disorders: Overview of treatment".) To avoid iron deficiency, adolescent females should be advised to consume iron-rich animal foods (ie, lean red meats, chicken, fish, and eggs) or good non-heme sources (ie, iron-fortified cereals, whole grains, dried beans, seeds, and nuts) (table 8) with foods rich in vitamin C (ie, citrus fruits, tomatoes, and pineapple). (See "Iron requirements and iron deficiency in adolescents".) Adolescents who shun milk should be encouraged to include other sources of calcium in their diets, such as low-fat yogurt, cheese, or calcium-enriched foods (table 3) [33,124]. (See "Calcium requirements in adolescents".) SUMMARY AND RECOMMENDATIONS Adolescence is a nutritionally vulnerable time period. Poor eating habits formed during adolescence can lead to obesity and diet-related diseases in later years [8,9,149-151]. In addition, the high incidence of dieting behaviors can contribute to nutritional inadequacies and to the development of eating disorders. Primary care providers are in an optimal position to provide nutrition screening, counseling, and referral to a dietitian if needed. The American Medical Association's Guidelines for Adolescent Preventive Services (GAPS) recommend that primary health care providers provide annual guidance regarding dietary habits, including the benefits of a healthy diet, ways to improve eating habits, and safe weight management. GAPS also recommends annual screening for eating disorders and obesity (table 9). These guidelines are also consistent with those outlined by the multidisciplinary task force, Bright Futures (www.brightfutures.org). Asking about main meals can provide a neutral opening to discuss more difficult topics [152]. (See "Guidelines for adolescent preventive services", section on 'Screening'.) We recommend the following general guidelines to clinicians working with adolescents: Use Choose my plate as a guide for a healthy diet and emphasize variety for supplying all the necessary nutrients for growth and development, as detailed at www.ChooseMyPlate.gov.

Recommend reduced-fat dairy and animal products, moderate portion sizes, and less frequent consumption of higher-fat items. Along with increased intake of fruits, vegetables, and whole grains, this suggestion can help adolescents achieve dietary guidelines without compromising energy and vitamin and mineral intakes. (See 'Dietary balance' above.) Adolescent girls should be advised to consume iron-rich animal foods or good non-heme sources (table 9) with foods rich in vitamin C. (See "Iron requirements and iron deficiency in adolescents".) Educate adolescents, particularly females, about the importance of calcium to bone health, recommended intakes, and good sources of calcium, particularly lower-fat calcium-rich dairy products and additional sources such as calcium-fortified foods (table 5). (See "Calcium requirements in adolescents".) Stress the importance of eating all meals, particularly breakfast. Adolescents should be informed that skipping meals does not help with weight control, and indeed may promote weight gain. (See 'Skipping meals' above.) Promote nutrient-dense snacks to help fill in nutrient gaps. (See 'Snacking' above.) Teach adolescents how to make nutritionally sound choices when faced with an array of attractive, but not necessarily healthy, foods. (See 'Fast foods' above.) Educate adolescents that "dieting" (the manipulation of food intake and food choices driven by weight concerns, as distinct from efforts to adopt healthy eating and other lifestyle behaviors in the interest of good health) is not healthy. Efforts at weight reduction can compromise nutrition, growth, and health and can increase the risk for the development of an eating disorder. (See 'Dieting' above.) Avoid categorizing foods as "good," "bad," "safe," or "fattening"; focus on foods that are recommended, rather than on foods to avoid. Emphasize that no one body type is ideal and that adolescents bodies develop at different rates; stress the importance of body diversity. Explain the importance of healthy eating habits to one's health, appearance, and energy.