6/2/2018 Adolescent eating habits - UpToDate

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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

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2018. | This topic last updated: Nov 17, 2017.

INTRODUCTION — Nutritional needs during adolescence are increased because of the increased growth rate and changes in body composition
associated with puberty [1-3]. 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 [1,4]. Unhealthy eating habits are seen in adolescents in the United States and many other countries [5-9].

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 [10-18]. For this reason, nutrition remains an important objective for Healthy People 2020 [19]. 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)
[20-23]. (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 [24-29]. 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, vitamin D, and zinc than is recommended [30-35]. The low intake of iron and calcium among adolescent girls
is of particular concern. Vitamin D deficiency is increasingly prevalent, and is associated with decreased bone density and probably fracture risk
[36,37]. Vitamin D deficiency is typically defined as 25-hydroxyvitamin D concentrations <15 ng/mL (37.5 nmol/L), and target concentrations for 25-
hydroxyvitamin D are at least 20 ng/mL (50 nmol/L). 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 [38-43]. (See "Iron requirements and iron
deficiency in adolescents" and "Calcium requirements in adolescents" and "Vitamin D insufficiency and deficiency in children and adolescents".)

Eating habits vary widely between individual adolescents, and also display some general trends over time, reflecting sociocultural trends in food
availability and nutritional goals. As an example, data from six national representative surveys showed that total energy intake among us adolescents
increased through 2004, then decreased through 2010 [44]. Seven food sources, including sugar-sweetened beverages, pizza, full-fat milk, grain-
based desserts, breads, pasta dishes, and savory snacks, consistently contributed to this trend. Intakes of full-fat milk, meats, ready-to-eat cereals,
burgers, fried potatoes, fruit juice, and vegetables decreased, whereas nonfat milk, poultry, sweet snacks and candies, and tortilla- and corn-based

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dishes increased through 2010. The changes contributing to the decline in caloric intake prior to 2010 included significant decreases in sugar-
sweetened beverages, pizza, pasta dishes, bread, and savory snacks; and significant increases in fruit.

During adolescence, young people are in a transition period when they gradually take over the responsibility for their own eating habits. Knowledge is
one of the factors necessary for a healthy transition of responsibility. Questionnaires used to assess nutrition knowledge demonstrate that more than
two-thirds of adolescents, especially boys, adolescents from rural environments, and overweight adolescents, have unsatisfactory knowledge about
dietary recommendations, sources of nutrients, diet-disease relationships, and dietary habits [45]. In this group, television was the main source of
information about nutrition for adolescents.

Parents have the opportunity to influence their child's dietary intake in a variety of ways, the most important of which is the decisions made about what
foods are available within their home [46]. Nutrition education interventions focusing on spices and herbs also may be an effective tool to improve diet
quality and healthy eating attitudes, especially among urban and African–American adolescents [47]. The addition of spices and herbs was associated
with modest improvement in the consumption of grain and protein food products, as well as attitudes toward eating vegetables, whole grains, lean
protein, and low-fat dairy products.

This topic review discusses characteristic adolescent eating habits, including skipping meals, fast food consumption, frequent snacking, and dieting
behaviors [1,48-50]. The nutritional requirements for adolescents are discussed separately. (See "Dietary energy requirements in adolescents".)

SKIPPING MEALS — Adolescents may skip meals because of irregular schedules [51]. Breakfast and lunch are the meals most often missed, but
social, school, and work activities can cause evening meals to be missed as well [1,52-54].

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) [1,52,55-58]. In a 2015 nationally
representative survey of high school students, only 36.3 percent ate breakfast for all seven days before the survey. Subgroups that were more likely to
consume breakfast all seven days were the 9th grade students (39.6 percent) compared with 12th grade students (33.8 percent), and boys (40.5
percent) compared with and girls (32.1 percent) [27]. More than one-half of the adolescents participating in the National Adolescent School Health
Survey reported they ate breakfast less than twice per week [48]. Reasons for skipping breakfast include lack of time, early school activities, proximity
of fast food outlets and grocery stores near schools [6], or a poor appetite first thing in the morning [1,59].

The omission of breakfast can affect school performance and the overall quality of the diet [60-63]. 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 [64]. 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 [65].

Total nutrient intakes are lower among adolescents who skip breakfast as compared with those who consume breakfast [1,5,63,66]. 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 [53,55,58,67-70]. When breakfast is consumed, it contributes to approximately one-fourth (21 to 26 percent) of total

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daily energy intake [71,72]. The foods that typically are skipped with breakfast include fruits, breads, and calcium- and iron-rich foods (milk and iron-
fortified cereals, respectively) [25,53,55,73-75]. Adolescents who skip breakfast tend not to compensate for these losses at other meals [60,73,76].

Adolescents' busy lifestyles often conflict with family mealtimes [1,77,78]. There is a decline in family meal frequency during adolescence, and family
meals are associated with higher diet quality [25,50,74,79-81]. 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 [82]. Compared with those who rarely eat with
their families, they consume less fried food and soft drinks and more fruits, vegetables, and whole grains [82]. 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 [25].

Adolescents, particularly females, may use skipping meals as a strategy for weight control [49,83,84]. However, the calories that are "saved" are often
made up through heavy snacking on nutrient-poor foods, or by overeating at the next meal [85]. This pattern tends to impair nutrition because
high-fat/energy-dense snack foods rarely compensate for the nutritional value of the meals that are skipped [52]. 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) [4].

● 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 [86].

● A cohort study examined 2379 adolescent girls aged 9 to 10 years at baseline, and followed them until 19 years of age [53,87]. Among girls with
high body mass index (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 [88].

● 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 [89]. This study found that breakfast skipping was associated with weight gain during this time
period.

● A study in Finland showed that the presence of fast food retailers near schools is associated with the accumulation of irregular eating habits,
skipping meals, and greater overweight among adolescents from low socioeconomic backgrounds [6].

● 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 [66].

Possible explanations for this finding include [88]:

● Adolescents perceive that they are reducing energy intake by skipping meals when in fact they are not

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● 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 [90,91]

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 [49,53,67,83,89,92]. A meta-analysis documented that higher eating frequency was associated with lower body weight status in
adolescents, especially among boys [93]. (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) [49,94,95]. (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 [48,52,71,96,97]. 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 [49,52,56,97]. Snacks are a major source of energy and
nutrients, providing nearly one-quarter to one-third of total energy intake for many adolescents [49,98]. In one study from Canada, after-school snacks
represented 13 percent of total daily energy intake; the largest energy contributors were energy-dense, nutrient-poor foods such as cookies, sugar-
sweetened beverages, and sweets [99].

Depending upon their timing and composition, between-meal snacks can contribute in negative or positive ways to the adolescent diet [100]. 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 [1,48,49]. In particular, sugar-sweetened beverages often have a negative impact on diet quality [33] and
also contribute to weight gain [101,102]. 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 [103]. Increased intake of sugar-sweetened beverages also may be an important predictor of
cardiometabolic risk independent of weight status [104]. Moreover, dietary sodium is associated with higher intake of sugar-sweetened beverages,
identifying a possible link between dietary sodium and excess energy intake [105]. In contrast, healthy snacks can help meet the increased energy and
nutrient needs of adolescence [2]. Snacks that are nutrient-dense (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 [1,49,106].

Television viewing is associated with increased snacking among children and adolescents and also with obesity [57,107]. Spending more than 120
minutes watching television is associated with significantly higher intakes of total fat and polyunsaturated fat and lower intake of several minerals and
vitamins [108]. Adolescents with high media exposure, including television and video and computer games, were more likely to drink sugar-sweetened
beverages rather than water or milk [109]. Exposure to advertising of poor quality snack foods appears to be an important mechanism for the
association between television viewing and food intake or obesity. 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 [110]. (See "Definition;
epidemiology; and etiology of obesity in children and adolescents", section on 'Environmental factors'.)

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Counseling — Adolescents should be taught how to improve the overall quality of their diets with nutritious snacks [1,48]. 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 [111]:

● 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 [10]. 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
[48,112,113]. Individuals younger than 18 years of age account for more than 80 percent of fast food restaurant visits [113,114]. 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) [115]. The most common beverage choices are carbonated soft drinks, coffee/tea, and milk (in that order) [115].
(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 [116-119]. 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) [1,31,48,116,117,120,121]. Fat provides more than 50 percent of the
calories in many fast food items [1,112]. 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. [112]. Increased fast food consumption
was associated with greater intakes of soft drinks and lower intakes of fruits, vegetables, grains, and milk [122,123]. Fast food consumption also has a
modest association with overweight status among adults [124,125] and adolescent girls [126]. (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 [127]. Healthier choices include salad bars, baked potatoes, steamed
vegetables, low-fat frozen yogurt, and lower-fat sandwiches (table 3) [1,48]. (See "Fast food for children and adolescents".)

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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 [48,106,128].

DIETARY BALANCE — The daily composition of a recommended diet is based upon the 2010 Dietary Guidelines for Americans [129], which are
taught by the United States Department of Agriculture (USDA) "Choose my plate" tool. "Choose my plate" replaced the Food Guide Pyramid in 2011
(www.ChooseMyPlate.gov) [95]. 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".)

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 daily for girls (1800 calorie diet), and 3 cups of vegetables and 2 cups of fruit daily for boys (2200 calorie diet).

Actual consumption of fruits and vegetables is well below these targets [130]. Using dietary recall data from the 2007 to 2010 National Health and
Nutrition Examination Survey applied to the 2013 Youth Risk Behavior Surveillance Survey, an estimated 8.5 percent of high school students met the
United States Department of Agriculture fruit recommendations, and 2.1 percent met the vegetable recommendations. The median consumption of
fruits and vegetables was 0.5 cup and 0.8 cup equivalents per day (100 percent fruit juice and fried potatoes were not included) [28]. 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) [131]. 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 three to four servings/day for
adolescents); low-fat or fat-free products are recommended. This target provides a substantial proportion of the recommended intake for calcium and
vitamin D, although actual intake is considerably lower among most adolescents in the United States.

The recommended dietary allowance (RDA) for calcium is 1300 mg for boys and girls 9 to 18 years of age. The recommended three to four
servings/day of dairy products provides 900 to 1200 mg of calcium, and many adolescents fail to meet this goal [27]. Calcium intake can be increased
to achieve the recommended level through foods that are naturally rich in calcium, calcium-fortified foods, and calcium supplements. (See "Calcium
requirements in adolescents", section on 'Recommended intake'.)

In the United States, the prevalence of vitamin D deficiency or insufficiency (defined in these studies as serum 25-hydroxyvitamin D concentrations
<20 ng/mL [50 nmol/L]) is about 15 percent in adolescents [132]. However, the prevalence varies considerably among different countries and
subpopulations because of differences in risk factors, including diet, skin pigmentation, sun exposure, and obesity.

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The recommended intake for vitamin D is 600 International Units daily, although some individuals appear to require higher vitamin D intake to maintain
serum concentrations in the target range. The recommended three servings of fortified dairy products provides about 350 International Units of Vitamin
D [133], which is about half of the recommended daily intake for adolescents. 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 of dairy products daily, or for those with low serum concentrations of 25-hydroxyvitamin D. (See "Vitamin D insufficiency
and deficiency in children and adolescents", section on 'Targets for vitamin D intake'.)

DIETING — It is common for adolescents to be unhappy with and self-conscious about their changing bodies [134]. 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 [10,135]. 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
[83,136,137]. 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 [138]. Weight concerns and dieting are so common among female adolescents that they are
considered to be normative [134,139].

Dieting and disordered eating behaviors in adolescents include [83,84,140-143]:

● 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 [142-146].

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Prevalence — A history of dieting can be obtained in approximately 40 to 70 percent of adolescents [27,84,147-150]. As indicated above, more
females than males diet (45 versus 20 percent in one study) [83,142], 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) [83,142,148].

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 [83,149,151,152]. They perceive themselves to be fat
although they are not. Self-perceived weight status is associated strongly with weight loss behaviors among adolescent females [151,153].

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
[148]. 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) [142]. Only 24 percent of the girls responding to the survey
actually were overweight or obese (body mass index [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: Overview of epidemiology, clinical features, and
diagnosis".)

According to the 2015 Youth Risk Behavior Surveillance Survey, a nationwide survey of high school students, 60.6 percent of females and 31.4
percent of males were attempting to lose weight [27]. In addition, 31.5 percent of students (38.2 percent of females, 25.3 percent of males) described
themselves as "slightly or very overweight." However, only 16 percent of these students (16.6 of percent females and 15.5 percent of males) were
overweight (BMI between the 85th and 95th percentile). An additional 13.9 percent of students (10.8 percent of females and 16.8 percent of males)
were obese (BMI ≥95th percentile). Overall, 27.1 percent of students reported daily vigorous physical activity, 29.8 percent attended physical education
classes five days a week, 24.7 percent watched three or more hours of television daily, and 41.7 percent used computers for something other than
school work for three or more hours daily.

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Effects on nutrition — Dieting behaviors can compromise intake of energy and nutrients that are essential for adolescents' growth and development.
Most 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 [154,155] (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) [41,94,156,157].

As an example, one study compared the diets of 16- to 17-year-old English girls who dieted to those who did not [158]. The mean energy intake of the
dieters was less than that of the nondieters (1604 versus 2460 kcal/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 [48]. 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) [159].

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) [43,160]. (See "Calcium requirements in adolescents".)

Avoidance of meats, eggs, and dairy products also can result in inadequate zinc intake 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" and "Vegetarian diets for
children", section on 'Zinc'.)

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 [143,161-163].

Adolescents who diet frequently are at increased risk for developing eating disorders such as anorexia nervosa and bulimia [156,164-167]. In one
three-year prospective study of 1728 14- to 15-year-old adolescents in Australia, girls who dieted at a moderate or severe level [168] were 5 and 18
times more likely to develop an eating disorder, respectively, than were girls who did not diet [165]. A longitudinal study of 2500 adolescents found that

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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 with nondieters [156]. Another study of 800 children and adolescents found a significant association
between weight reduction efforts during adolescence and subsequent development of bulimia [169]. (See "Eating disorders: Overview of epidemiology,
clinical features, and diagnosis".)

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 [88,90,138,167,170-172]. 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 [91]. 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 BMI increased by 4.63 kg/m2 among adolescents using these unhealthy dieting
behaviors, as compared with 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 [94,139].

Because of the dramatic increase in the proportion of obese adolescents in the United States between 1980 and 2012 (quadrupled from 5 to 20.5
percent) [173-175], dieting is a much debated issue [165,176,177]. Unless medically indicated and guided toward healthy eating behaviors, dieting can
be unhealthy for a growing adolescent even if he or she is overweight [165,178,179]. 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 [178,180-183].

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 [140,143-145,184]. 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 [94]. Referral to a multidisciplinary team or professional with expertise
in eating disorders is indicated if an eating disorder is suspected. The team can consist of psychiatrists or psychologists, adolescent medicine
physicians, dietitians, and exercise therapists with the necessary experience in treating eating disorders. (See "Eating disorders: Overview of
epidemiology, clinical features, and diagnosis" and "Eating disorders: Overview of prevention and 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) [43,160]. (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 [11,12,185-187]. In addition, the high incidence of dieting behaviors can contribute to nutritional
inadequacies and to the development of eating disorders.
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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. 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 [188]. (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 8) 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.

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173. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010.
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175. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014; 311:806.
176. Troiano RP, Flegal KM, Kuczmarski RJ, et al. Overweight prevalence and trends for children and adolescents. The National Health and Nutrition
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177. McBean LD, Miller GD. Enhancing the nutrition of America's youth. J Am Coll Nutr 1999; 18:563.
178. Kirk S, Scott BJ, Daniels SR. Pediatric obesity epidemic: treatment options. J Am Diet Assoc 2005; 105:S44.
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179. Viner R, Bryant-Waugh R, Nicholls D, Christie D. Childhood obesity. Aim should be weight maintenance, not loss. BMJ 2000; 320:1401; author
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180. Ackard DM, Neumark-Sztainer D, Story M, Perry C. Overeating among adolescents: prevalence and associations with weight-related
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182. Philippas NG, Lo CW. Childhood obesity: etiology, prevention, and treatment. Nutr Clin Care 2005; 8:77.
183. Dietz W. How to tackle the problem early? The role of education in the prevention of obesity. Int J Obes Relat Metab Disord 1999; 23 Suppl 4:S7.
184. Shepherd LM, Neumark-Sztainer D, Beyer KM, Story M. Should we discuss weight and calories in adolescent obesity prevention and weight-
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185. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003; 289:76.
186. Calderon KS, Yucha CB, Schaffer SD. Obesity-related cardiovascular risk factors: intervention recommendations to decrease adolescent obesity.
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187. Ford ES, Mokdad AH, Ajani UA. Trends in risk factors for cardiovascular disease among children and adolescents in the United States. Pediatrics
2004; 114:1534.
188. American Medical Association. Guidelines for adolescent preventive services. American Medical Association, Chicago 1992.

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GRAPHICS

Healthy People 2020: Selected nutrition objectives

Weight status 2020 targets*

Reduce the proportion of children 2 to 5 years who are obese 9.6 percent

Reduce the proportion of children 6 to 11 years who are obese 15.7 percent

Reduce the proportion of adolescents who are obese 16.1 percent

Reduce the proportion of adults who are obese 30.6 percent

Food and nutrient consumption (2 years and older) 2020 targets ¶

Increase the contribution of fruits to the diet 0.9 cup-equivalents per 1000 calories

Increase the contribution of vegetables to the diet, with at least one-third of these servings being dark green or 1.1 cup-equivalents total vegetables per 1000
deep yellow vegetables calories

Increase the contribution of whole grains to the diet 0.6 ounce-equivalents of whole grains per 1000
calories

Reduce the consumption of calories from solid fats and saturated fat Solid fats no more than 16.7 percent of caloric
intake
Saturated fats no more than 9.5 percent of
caloric intake

Reduce the consumption of calories from added sugars Added sugars no more than 10.8 percent of
caloric intake

Increase consumption of calcium 1300 milligrams daily

* Target selected to represent a 10 percent improvement over baseline. In children and adolescents, obesity is defined as ≥95th percentile of body mass index (BMI) for
age and gender. In adults, obesity is defined as BMI ≥30.
¶ Target selected to represent an achievable shift in the population intake, based on past trends and consideration of the target's applicability to subpopulations.

From US DHHS. Healthy People 2020: Nutrition and weight status objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?
topicId=29 (accessed 3/27/2012).

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Content of typical fast food meals in energy (calories) and fat

Menu item Energy, kcal Fat, g Fat, percent of energy

Menu #1: (McDonald's)

Hamburger 250 9 32

Small fries 230 11 43

Baked apple pie 260 13 45

Soft drink (16 ounces) 170 0 0

Total 910 33 33

Menu #2: (Kentucky Fried Chicken)

Extra crispy fried leg and thigh 490 34 62

Mashed potatoes and gravy 130 5 35

Biscuit 180 8 40

Soft drink (16 ounces) 180 0 0

Total 980 47 43

Menu #3: (McDonald's)

Big Mac hamburger 540 29 48

French fries (large) 500 25 45

Baked apple pie 260 13 45

Soft drink (large: 32 oz) 310 0 0

Total 1610 67 37

Menu #4: (Burger King)

Triple whopper hamburger 1140 75 59

French fries (large) 540 27 45

Apple fries 70 1 13

Soft drink (large: 42 oz) 380 0 0

Total 2130 103 44

Data from: Wake Forest University Baptist Medical Center Drive thru Diet (available at www1.wfubmc.edu/Nurtition/Count+Your+Calories/dtd.htm). Additional data from:
www.mcdonalds.com; www.kfc.com/nutrition; and www.burgerking.com.

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Healthier fast food meals

Food item Energy, kcal Fat, g Fat, percent of energy

Menu #1: (Chick-Fil-A)

Grilled chicken sandwich (with mustard, lettuce, and tomatoes) 290 4 10

Fresh fruit cup (medium) 70 0 0

Yogurt cone 170 4 23

Chocolate milk 150 2 9

Total 680 10 13

Menu #2: (Wendy's)

Chili (small) 200 6 27

Baked potato (plain) 280 0 0

Mandarin oranges 80 0 0

Frozen yogurt dessert (small) 330 8 22

Total 890 14 14

Data from: Wake Forest University Baptist Medical Center Drive thru Diet (available at www1.wfubmc.edu/Nurtition/Count+Your+Calories/dtd.htm). Additional data
from: www.chickfila.com and www.wendys.com.

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Recommended daily amount from each food group, by calorie level

Calorie level
Food group
1200 1400 1600 1800 2000 2200 3000

Grains* 4 ounces 5 ounces 5 ounces 6 ounces 6 ounces 7 ounces 10 ounces

Vegetables ¶ 1.5 cups 1.5 cups 2 cups 2.5 cups 2.5 cups 3 cups 4 cups

Fruits Δ 1 cup 1.5 cups 1.5 cups 1.5 cups 2 cups 2 cups 2.5 cups

Dairy ◊ 2.5 cups 2.5 cups 3 cups 3 cups 3 cups 3 cups 3 cups

Protein foods 3 ounces 4 ounces 5 ounces 5 ounces 5.5 ounces 6 ounces 7 ounces

* In general, 1 slice of bread, 1 cup of ready-to-eat cereal, or ½ cup of cooked rice, cooked pasta, or cooked cereal can be considered as 1 ounce equivalent from the
Grains Group. At least half of these servings should be whole grains.
¶ 1 cup vegetables is approximately equal to 12 baby carrots, or one large tomato. Because of high water content, a serving of lettuce must be twice as large (1 cup of
lettuce = 1/2 cup of other vegetables).
Δ 1 cup of fruit is approximately equal to one apple or banana, 2 plums, 1/8th melon, or eight strawberries.
◊ Milk should be fat-free or low-fat after two years of age.

Data from: the United States Department of Agriculture "Choose My Plate" website, available at: www.choosemyplate.gov.

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Dietary sources of absorbable calcium, in comparison to milk

Number of
Fractional Estimated
Calcium content ¶ servings needed
Food Serving size* (g) absorption Δ, absorbable
(mg) to equal 240 mL
(percent) calcium ◊ (mg)
milk

Milk 240 300 32.1 96.3 1

Beans
Pinto 86 44.7 26.7 11.9 8.1
Red 172 40.5 24.4 9.9 9.7
White 110 113 21.8 24.7 3.9

Bok choy 85 79 53.8 42.5 2.3

Broccoli 71 35 61.3 21.5 4.5

Cheddar cheese 42 303 32.1 97.2 1

Cheese food 42 241 32.1 77.4 1.2

Chinese cabbage flower 85 239 39.6 94.7 1

leaves

Chinese mustard greens 85 212 40.2 85.3 1.1

Fruit punch with calcium 240 300 52 156 0.62

citrate malate

Kale 85 61 49.3 30.1 3.2

Spinach 85 115 5.1 5.9 16.3

Sweet potatoes 164 44 22.2 9.8 9.8

Rhubarb 120 174 8.54 10.1 9.5

Tofu with calcium 126 258 31 80 1.2

Yogurt 240 300 32.1 96.3 1

* Based on half-cup serving size (~85 g for green leafy vegetables) except for milk and fruit punch (1 cup or 240 mL) and cheese (1.5 ounces).
¶ From references 4 and 5 (averaged for beans and broccoli processed in different ways) except for the Chinese vegetables, which were analyzed in our laboratory.
Δ Adjusted for load by using the equation for milk (fractional absorption = 0.889-0.0964 in load (6)) then adjusted for the ratio of calcium absorption of the test food
relative to milk tested at the same load, the absorptive index. The absorptive index was taken from the literature for beans (7), bok choy (8), broccoli (8), Chinese
vegetables (9), fruit punch with calcium citrate mulate (10), kale (8), sweet potatoes (9), rhubarb (9), tofu (11), and dairy products (12).
◊ Calculated as calcium content x fractional absorption.

Reproduced with permission from: Weaver CM, Proulx WR, Heaney R. Choices for achieving adequate dietary calcium with a vegetarian diet. Am J Clin Nutr 1999; 70
(suppl):543S. Copyright ©1999, American Society for Clinical Nutrition.

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Zinc content of selected foods

Food Amount Zinc

Oysters 6 medium 80 mg

84 g

Liver 3.5 oz 6.1 mg

100 g

Hamburger 3.5 oz 4.9 mg

100 g

Cheerios 1 cup 3.7 mg

22.4 g

Sunflower seeds 1 oz 1.6 mg

28 g

Pecans 1 oz 1.5 mg

28 g

Chicken (white meat) 3.5 oz 1.0 mg

100 g

Milk (whole, skim) 1 cup 0.9 mg

240 g

Brown rice 1/2 cup 0.6 mg

97 g

Egg (1 whole) 1 large 0.5 mg

50 g

White rice 2/3 cup 0.4 mg

124 g

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Eating attitudes test

Always Usually Often Sometimes Rarely Never Score

1. Am terrified about being overweight 0 0 0 0 0 0 ___

2. Avoid eating when I am hungry 0 0 0 0 0 0 ___

3. Find myself preoccupied with food 0 0 0 0 0 0 ___

4. Have gone on eating binges where I feel that I may not be able to stop 0 0 0 0 0 0 ___

5. Cut my food into small pieces 0 0 0 0 0 0 ___

6. Aware of the calorie content of foods that I eat 0 0 0 0 0 0 ___

7. Particularly avoid foods with high carbohydrate content (ie, bread, rice, 0 0 0 0 0 0 ___
potatoes, etc)

8. Feel that others would prefer if I ate more 0 0 0 0 0 0 ___

9. Vomit after I have eaten 0 0 0 0 0 0 ___

10. Feel extremely guilty after eating 0 0 0 0 0 0 ___

11. Am preoccupied with a desire to be thinner 0 0 0 0 0 0 ___

12. Think about burning up calories when I exercise 0 0 0 0 0 0 ___

13. Other people think that I am too thin 0 0 0 0 0 0 ___

14. Am preoccupied with the thought of having fat on my body 0 0 0 0 0 0 ___

15. Take longer than others to eat my meals 0 0 0 0 0 0 ___

16. Avoid foods with sugar in them 0 0 0 0 0 0 ___

17. Eat diet foods 0 0 0 0 0 0 ___

18. Feel that food controls my life 0 0 0 0 0 0 ___

19. Display self-control around food 0 0 0 0 0 0 ___

20. Feel that others pressure me to eat 0 0 0 0 0 0 ___

21. Give too much time and thought to food 0 0 0 0 0 0 ___

22. Feel uncomfortable after eating sweets 0 0 0 0 0 0 ___

23. Engage in dieting behavior 0 0 0 0 0 0 ___

24. Like my stomach to be empty 0 0 0 0 0 0 ___

25. Enjoy trying new rich foods 0 0 0 0 0 0 ___

26. Have the impulse to vomit after meals 0 0 0 0 0 0 ___

For all items except #25, responses receive the following value:

Always = Usually = Often = Sometimes = Rarely = Never =

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3 2 1 0 0 0

For item #25, the responses receive these values:

Always = Usually = Often = Sometimes = Rarely = Never =

0 0 0 1 2 3

The cutoff score in screening patients for the presence of a DSM-IV eating disorder is 20 [1].

References:
1. Mintz LB, O'Halloran MS. The Eating Attitudes Test: validation with DSM-IV eating disorder criteria. J Pers Assess 2000; 74:489.

Reproduced with permission from: Garner DM, Garfinkel PE. Psychol Med 1979; 9:273. Copyright © 1979 Cambridge University Press.

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Dietary sources of iron

Food Approximate measure Iron (mg)

High iron sources

Cream of Wheat (quick or instant)* 1/2 cup 7.8

Kidney, beef ¶ 2 oz (60 g) 5.3

Liver, beef ¶ 2 oz (60 g) 5.8

Liver, calf ¶ 2 oz (60 g) 9

Liver, chicken ¶ 2 oz (60 g) 6

Liverwurst ¶ 2 oz (60 g) 3.6

Prune juice 1/2 cup 5.1

Spinach 1/2 cup 3.2

Moderate iron sources

All-Bran cereal 1/2 cup 2.9

Almonds, dried unblanched 1/2 cup 3

Dried beans and peas

Baked beans, no pork 1/4 cup 1.5
Blackeye peas, cooked 1/4 cup 0.8
Chick peas, dry 1/4 cup 3.5
Great northern beans, cooked 1/4 cup 1.3
Green peas, cooked 1/4 cup 1.4
Lentils, dry 1/4 cup 3.4
Lima beans, cooked 1/4 cup 1.3
Navy beans, cooked 1/4 cup 1.3
Red beans, dry 1/4 cup 3.5
Soybeans, cooked 1/4 cup 1.4
White beans, dry 1/4 cup 3.9

Beef, cooked 2 oz (60 g) 2-3 Δ

Ham, cooked 2 oz (60 g) 1.3

Lamb, cooked 2 oz (60 g) 1.9

Peaches, dried 1/4 cup 2.4

Peanuts, roasted without skins 3 1/2 oz (100 g) 3.2

Pork, cooked 2 oz (60 g) 2-3 ◊

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Prunes, dried 2 large 1.1

Scallops 2 oz (60 g) 1.6

Turkey, cooked 2 oz (60 g) 1.7

Approximate iron content of children's favorite foods

Hamburger, small 1 3
Large 1 5.2
Big Mac 1 4.3
Quarter Pounder 1 5.1

Spaghetti with meatballs 1 cup 3.3

Frankfurter and beans 1 cup 4.8

Pork and beans 1 cup 5.9

Raisins § 5/8 cup 3.5

Cereals, fortified 1 serving 4.5-17.8

Nuts § 1 cup 5-7

Seeds, sunflower § 3 1/2 oz (100 g) 7.1

Chile con carne 1 cup 3.6

Beef burrito or tostado 1 medium 3.4-4.6

Cheese pizza 2 slices 3

Cheese pizza with beef 2 slices 4.8

White bread 1 piece 0.7

* Or other fortified cereals which contain 10 mg of iron per ounce or 100 percent RDA per serving.
¶ As organ meats are generally high in cholesterol, these iron-rich foods should be eaten in moderation.
Δ Depending on cut, the greatest amounts of iron are generally found in the chuck, flank, and bottom round cuts of beef.
◊ Depending on cut, the greatest amounts of iron are generally found in the loin, sirloin, tenderloin, and picnic shoulder cuts of pork.
§ Raisins, nuts, and seeds are not generally recommended for children under age three because of risk of choking.

Data from: Walker WA, Watkins JB (Eds), Nutrition in Pediatrics, 2nd ed, BC Decker, Inc, London 1997.

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Contributor Disclosures
Debby Demory-Luce, PhD, RD, LD Nothing to disclose Kathleen J Motil, MD, PhD Consultant/Advisory Boards: Mallinckrodt
Pharmaceuticals/InfaCare Pharmaceutical Corporation [Jaundice (Stannsoporfin)]. Amy B Middleman, MD, MPH, MS Ed Nothing to disclose Alison
G Hoppin, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level
review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

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