Adolescence • is the transition period between childhood and adulthood, a time of life that begins at puberty. For girls, puberty typically occurs between ages 12 and 13, while for boys it occurs between ages 14 and 15.
• It is between 12-21 years old.1 • It is one of the fastest growth periods of a person's life . Life-long food habits

are established during adolescence. During this important time, there a high incidence of nutritional deficiencies and poor eating habits. Immediate and long-term complications include obesity, hyperlipidemia, osteoporosis, sexual maturation delays, and final adult height. Development of eating disorders is prominent during this period. In addition, the prevalence of obesity or risk of future obesity is increasing (30% of children age 6-19 are overweight or at risk of being overweight). The highest prevalence of nutritional deficiencies occur during adolescence.

It is important for the pediatrician to be familiar with normal daily requirements and be able to detect when there are deviations. A diet and nutritional history is necessary while assessing adolescents at their checkups. Nutrition is important to overall health. Proper nutrition can also prevent many medical problems, including becoming overweight, developing weak bones, and developing diabetes. It will also ensure that your child physically grows to full potential.2-7 The best nutrition advise to keep your adolescent healthy includes encouraging to: • Eat a variety of foods • Balance the food you eat with physical activity • Choose a diet with plenty of grain products, vegetables and fruits • Choose a diet low in fat, saturated fat, and cholesterol • Choose a diet moderate in sugars and salt • Choose a diet that provides enough calcium and iron to meet their growing body's requirements. You can also help promote good nutrition by setting a good example. Healthy eating habits and regular exercise should be a regular part of your family's life. It is much easier if everyone in the house follows these guidelines, than if your child has to do it alone. You should also buy low-calorie and low fat meals, snacks and desserts, low fat or skim milk and diet drinks. Avoid buying high calorie desserts or snacks, such as snack chips, regular soft drinks or regular ice cream.

The Food Guide Pyramid was designed by the US Dept. of Agriculture to promote healthy nutrition in children over two years of age. It is meant to be a general guide to daily food choices. The main emphasis of the Food Guide Pyramid is on the five major food groups, all of which are required for good health. It also emphasizes that foods that include a lot of fats, oils and sweets should be used very sparingly. The Food Pyramid shows a range of servings for each food group. How much you actually eat depends on your age and activity level. Teenage boys who are active require about 2800 calories and should eat the highest range of servings. Teenage girls who are active require about 2200 calories and should eat servings in the middle of the range of servings. Children who are overweight and dieting should at least eat the lowest range of servings. When determining how many servings to eat, it is important to look at the serving size. Larger portions should count as more than one serving, and smaller portions will count as only a part of a serving.8

Food Guide Pyramid

Fats, Oils and Sweets
No more than 30% of your diet should come from fats. For a 2200 calorie diet, that would equal 73g of fat each day and for a 2800 calorie diet, 93g of fat each

day. The type of fat that you eat is also important. Saturated fats in foods such as meats, dairy products, coconut, palm and palm kernal oil, raise cholesterol more than unsaturated fats, which are found in olive, peanut, and canola oils, or polyunsaturated fats in safflower, sunflower, corn, soybean and cottonseed oils. Limit saturated fats to no more than 10% of daily calories. Sugars supply a large amount of calories, with little nutritional value. They include white sugar, brown sugar, corn syrup, honey and molasses and foods like candy, soft drinks, jams, and jellies. Selection tips: • use lean meats and skim or low fat dairy products • use unsaturated vegetable oils and margarines that list a liquid vegetable oil as the first ingredient on the label • read the nutrition label on foods to check for the amount and type of fat it includes • • • limit foods that contain a large amount of saturated fats limit foods high in sugar and avoid adding extra sugar to your foods examples: Grams of Fat Servings Food 4 11 7 6 10 9 Butter, margarine, 1 tsp. Mayonnaise, 1 tbs. Salad dressing, 1 tbs. Sour cream, 2 tbs. Cream cheese, 1 oz. Chocolate bar, 1 oz.

Milk, Yogurt and Cheese
Dairy products provide protein, vitamins and minerals and are an excellent

source of calcium. Your adolescent should have 2 to 3 servings of milk, yogurt and cheese each day. Selection tips: • • • Choose skim milk and nonfat yogurt Avoid high fat cheese and ice cream examples: Grams of Fat Servings Food Trace Trace 5 8 5 4 18 7 5 7 3 2 1 1 1 1 1 1 1 1 1/4 1/3 1/3 1/2 Skim milk, 1 cup Nonfat yogurt, 8 oz. Low fat milk, 1 cup Whole milk, 1 cup Chocolate milk, 2%, 1 cup Low fat yogurt, 1 cup Process cheese, 2 oz. Mozzarella, part skin 1 1/2 oz Cottage cheese, 1/2 cup Ice cream, 1/2 cup Ice milk, 1/2 cup Frozen yogurt, 1/2 cup

Meat, Poultry, Fish , Dry Beans, Eggs and Nuts
Foods in this group provide protein, and vitamins and minerals, including B vitamins, iron and zinc. You should have 2 to 3 servings of foods from this group each day, including the equivalent of 5 to 7 ounces of lean meat. Selection tips: • A serving from this food group can include 2-3 ounces of lean meat, poultry or fish, which may be an average hamburger or medium chicken breast half. • Choices with the least fat include lean meat, poultry without skin, fish, and

dry beans and peas. • Prepare meats in low fat ways, by trimming away fat, and broiling, roasting, or boiling rather than frying. • Remember that nuts and seed are high in fat, and egg yolks are high in cholesterol, so you should eat them in moderation. • examples: Grams of Fat Servings Food 6 16 13 16 5 Trace 16 22 3 oz 3 oz 3 oz 1 oz 1 oz 1 oz 1 oz 1 oz Lean meat, poultry, fish Ground beef, lean Chicken, with skin, fried Bologna, 2 slices Egg, 1 Dry beans and peas, 1/2 cup Peanut butter, 2 tbs. Nuts, 1/3 cup Servings = ounces of meat these items count as.

Vegetables supply you with vitamins, including vitamin A and C, and folate, minerals, such as iron and magnesium, and fiber. Plus they are low in fat. You should have 2 to 4 servings of vegetables each day. Selection tips: • You should eat a variety of vegetables to provide you with all of the different nutrients that they supply, including dark green leafy vegetables, deep yellow vegetables, starchy vegetables (potatoes, corn peas), legumes (navy, pinto and kidney beans), and other vegetables (lettuce, tomatoes, onions, green beans). • Do not add a lot of fat to the vegetables you eat, by avoiding added toppings, such as butter, mayonnaise, and salad dressings. • examples: Grams of Fat Servings Food Trace Trace 1 1 Vegs, cooked, 1/2 cup Vegs, leafy, raw 1 cup

Trace 4 8 8

1 1 1 1

Vegs, non leafy, raw, 1/2 cup Potatoes, scalloped, 1/2 cup Potato salad, 1/2 cup French fries, 10

Fruits and 100% fruit juices provide Vitamin A and C and potassium. They are also low in fat and sodium. Selection tips: • Eat fresh fruits and 100 % fruit juices and avoid canned fruit in heavy syrups and sweetened fruit juices. • • • Eat whole fruits. Eat citrus fruits, melons, and berries, which are high in Vitamin C. examples: Grams of Fat Trace Trace Trace 9 Servings Food 1 1 1 1 Whole fruit Fruit, raw or canned, 1/2 cup Fruit juice, unsweetened, 3/4 cup Avocado, 1/4 whole

Bread, Cereal, Rice and Pasta
Foods from this group provide complex carbohydrates (starches) and provide vitamins, minerals, and fiber. You need at least 6 to 11 servings of foods from this food group each day. Selection tips: • • • Choose whole grain breads and cereals for added fiber. Choose foods that are low in fat and sugars. Avoid adding calories and fat to foods in this group by not adding spreads

or toppings high in fat. • examples:

Grams of Fat Servings Food 1 2 3 Trace ? 3 12 11 13 13 4 1 2 1 1 1 2 2 2 2 1 1 Bread, 1 slice Hamburger roll Tortilla Rice, pasta, 1/2 cup Breakfast cereals, 1 oz Pancakes, 2 Croissant, 1 large Doughnut, 1 medium Danish, 1 medium Cake, frosted, 1 slice Cookies, 2 medium

Calcium Requirements
Calcium is a mineral that is mostly present in your child's bones. Having a diet with foods that are high in calcium to meet daily requirements is necessary for the development of strong bones. It is also an important way to prevent the development of osteoporosis in adults. Adolescents require about 1200 to 1500 mg of calcium each day. See the table below for the calcium content of common foods and check the nutrition label to choose foods high in calcium when you prepare your families diet. Also choose foods that are fortified with calcium. examples: Calcium Content Servings Food

300 mg 113 mg 35 mg 35 mg 300 mg 300 mg 300 mg 40-50 mg 44 mg

1 cup 1/2 cup 1/2 cup 1 cup 1.5 oz 8 oz 1 cup 1 1/2 cup

Milk, whole or low fat White beans Broccoli, cooked Broccoli, raw Cheddar cheese Yogurt, low fat Orange juice, calcium fortified Orange, medium Sweet potatoes, mashed

Iron Requirements
Iron is another mineral that is important for your child's growth. Having a diet with foods that are high in iron to meet daily requirements is necessary for the development of strong muscles and production of blood. Adolescents require about 12 (males) to 15 (females) mg of iron each day. See the table below for the iron content of common foods and check the nutrition label to choose foods high in iron when you prepare your families diet. Good sources of iron include beef, chicken, pork, legumes (including beans and peanuts), enriched or whole grains, and leafy green vegetables such as spinach . A deficiency of iron causes anemia , which leads to fatigue , confusion, and weakness.

Zinc requirements:
Needs about 12-15 mgs/day. Found in meats, eggs, seafood, and dairy products

Fiber requirements:

Needs 20-25 grams/day. Found in fruits, vegetables, grains, beans, and cereals.

Vitamins requirements:
Most commonly adolescents are deficient A, B6, E, D, C, and folic acid. Usually, adolescents who are eating normal daily requirements of nutrients are not deficient in vitamins. Vitamin supplements may be added to meet requirements.

Vitamin D
400 IU/day. Found in fortified milk and cereal, egg yolks. Prevalence of deficiency is 14%; 20 times higher in non-Hispanic, black adolescents, twice as high in females and inversely related to weight (using the definition of vitamin D deficiency as a serum level of 25-hydroxy vitamin D <20 ng/mL)

Many adolescents ignore the role that fluids play in nutrition. It is important to moderate drinking of high-sugar beverages and fruit juices especially between meals. Caffeine from sodas and coffee drinks can interfere with sleep if consumed late at night, which already is a health and school performance issue for many teens. The Dietary Guidelines also say that adolescents should not drink alcoholic beverages. Adolescents need to drink an adequate amount of water..

Performance Enhancing” Supplements
Creatine – a combination of glycine, arginine and methionine that facilitates production of adenosine triphosphate and increases free energy for muscle contractions. Not well studied in adolescents but in adults, creatine does not improve long duration aerobic performance. Side effects include weight gain, headache, diarrhea, muscle strain and potentially increased risk of renal damage.


DHEA and androstenedione – precursors to testosterone. Not well-studied but side effects include HTN, hyperinsulinism, depression, paranoia, acne, as well as irreversible virilization in females and gynecomastia in males.

BMI-for-age weight status categories and the corresponding percentiles are shown in the following table.
Weight Status Category Percentile Range

Less than the Underweight 5th percentile

5th percentile to less Healthy weight than the 85th percentile

In the case of children and teens, the BMI, also called as BMI-for-age, cannot always be consistent. Since it is based on the height and weight of the child or teen, and they continuously grow, their amount of body fat also changes continuously as they mature. Also, teen boys grow at a different rate than teenage girls do. That is the reason that the BMI tends to be age and gender specific and is not always reliable for children and teens.

The guidelines for body types for children and teens are usually done At risk of overweight with respect to an important statistic than the 95th percentile called BMI percentile. This statistic compares the person's BMI to thousands of other people under the Equal to or greater than same reference sample, so as to Overweight enable a comparative study of that the 95th percentile person's health with respect to the rest of the population within permissible constraints. People are considered to be underweight if they are in the lowest 5% of the people studied and overweight if they are in the top 5%. People are considered to be in the normal weight range if they are in the middle 90%.
85th percentile to less


The BMI-for-age is a useful tool because it can be used for adolescents and children even beyond puberty. It compares well with the laboratory results of the body fat and can be used to keep a track of the body size through-out the child's or the adolescent's life. The following charts of BMI for Boys and Girls according to the age

2 to 20 years: Boys & Girls Body mass index-for-age percentiles

Eating and Snacking Patterns 9
Adolescents tend to eat differently than they did as children. With afterschool activities and active social lives, teens are not always able to sit down for three meals a day. Busy schedules may lead to meal skipping, snacking throughout the day, and more eating away from home. Many teens skip breakfast, for example, but this meal is particularly important for getting enough energy to make it through the day, and it may even lead to better academic

performance. When teens skip meals, they are more likely to grab fast food from a restaurant, vending machine, or convenience store. These foods are high in fat and sugar and tend to provide little nutritional value. In addition, eating too many fast foods can lead to weight gain and, in some cases, diabetes and heart disease .

Dietary decisions made in adolescence may have lasting health effects. For example, in the United States, more than 85 percent of teen girls and about 65 percent of teen boys do not include enough calcium in their diets. Such deficiency increases their chances of developing osteoporosis as adults. Eating meals and snacking away from home puts the responsibility for good food choices right in adolescents' hands. Snacks should be low in both fat and added sugar. Some healthful snack ideas include fresh fruit, sliced vegetables with low-fat dip, low-fat yogurt, low-fat string cheese, peanut butter and crackers, baked chips, granola bars, and graham crackers. Juices, fruit drinks, and sodas are usually very high in calories from natural or added sugar, so they should be consumed in moderation. The Food Guide Pyramid is an appropriate guide for adolescents' food choices, even when snacking . Evaluation of adolescent nutrition should include: Weighing and measuring and comparing to reference values. Make note of any weight loss, excessive gains in weight, or failure to grow. • Amount of physical activity

• •

Quality, quantity, and number of meals per day. Sexual maturation and menstruation history.

Risks for Nutritional Deficiencies increased in: • • • • • Eating disorders Chronic medical conditions Use of alcohol or drugs Strict Vegan diet Low socio-economic status

High-Risk Groups
Certain groups of adolescents may be at risk for nutritional inadequacies. 1. Pregnant Teens. When a teenager becomes pregnant, she needs enough nutrients to support both her baby and her own continued growth and physical development. If her nutritional needs are not met, her baby may be born with low birth weight or other health problems. For the best outcome, pregnant teens need to seek prenatal care and nutrition advice early in their pregnancy. 2. Athletes. Adolescents involved in athletics may feel pressure to be at a particular weight or to perform at a certain level. Some young athletes may be tempted to adopt unhealthful behaviors such as crash dieting, taking supplements to improve performance, or eating unhealthful foods to fulfill their hearty appetites. A balanced nutritional outlook is important for good health and athletic performance.

3. Vegetarians. A vegetarian diet can be a very healthy option. However, adolescents who follow a vegetarian diet, whether for religious or personal reasons, need to carefully plan their intake to get the protein and minerals they need. Strict vegetarians (those who do not eat eggs or dairy products), also known as vegans, may need nutritional supplements to meet their needs for calcium, vitamin B 12, and iron.

Potential Nutrition-Related Problems
Adolescents are at risk for obesity , obesity-related chronic diseases, and eating disorders. 1. Obesity, Diabetes, and Heart Disease. All over the world, adolescent obesity is on the rise. This has led to an increase in obesity-related diseases like diabetes and heart disease. Experts believe this rise in obesity is due to lack of physical activity and an increase in the amount of fast food and "junk food" available to adolescents. Staying active and eating foods that are low in fat and sugar promote a healthy weight for teens. 1013

2. Eating Disorders. Adolescents tend to be very conscious of appearances and may feel pressure to be thin or to look a certain way. Fear of gaining weight may lead to overly restrictive eating habits. Some teens resort to self-induced vomiting or laxative use to control their weight. Both boys and girls are affected by eating disorders. Teens who suspect they have a problem with body image or eating habits should talk to a trusted adult.


Physically, adolescents with eating disorders form a spectrum, from the extremely thin to the extremely heavy, as the drawing above illustrates. Between the extremes are various types of physiques. Along the spectrum, adolescents with disordered eating behaviors have underlying problems interfering with normal nourishment; they use food inappropriately.

Anorexia nervosa
Anorexia nervosa, commonly referred to simply as anorexia, is one type of eating disorder and a psychological disorder. A person with anorexia often initially begins dieting to lose weight. The individual continues the endless cycle of restrictive eating, often accompanied by other behaviors such as excessive exercising or the overuse of diet pills, diuretics, laxatives, and/or enemas in order to reduce body weight, often to a point close to starvation in order to feel a sense of control over his or her body. This cycle becomes an obsession and, in this way, is similar to any type of addiction.

Causes of anorexia
Approximately 95% of those affected by anorexia are female, but males can develop the disorder as well. While anorexia typically begins to manifest itself during early adolescence, it is also seen in young children and adults.Research within the medical and psychological fields continues to explore possible causes as:- genetic component may determin a person's susceptibility to anorexia. Researchers are currently attempting to identify the particular gene or genes that might affect a person's tendency to develop this disorder. Hypothalamic factor (which regulates certain metabolic processes) contributing to the development of anorexia. Imbalances in neurotransmitter (brain chemicals involves in signaling and regulatory processes) levels in the brain may occur in people suffering from anorexia. Feeding problems as an infant, a general history of undereating, and maternal depressive symptoms tend to be risk factors for developing anorexia. Personal characteristics that can predispose an individual to the development of anorexia include a high level of negative feelings and perfectionism.

There are four basic criteria for the diagnosis of anorexia nervosa that are characteristic: 1. The refusal to maintain body weight at or above a minimally normal

weight for age and height. Maintaining a body weight less than 85% of the expected weight. 2. An intense fear of gaining weight or becoming fat, even though the person is underweight.


Self-perception that is grossly distorted, excessive emphasis on body

weight in self-assessment, and weight loss that is either minimized or not acknowledged completely.

In women who have already begun their menstrual cycle, at least

three consecutive periods are missed (amenorrhea), or menstrual periods occur only after a hormone is administered

Clinical picture
Psychological and behavioral Anorexia can have dangerous psychological and behavioral effects on all aspects of an individual's life and can affect other family members as well.

The individual can become seriously underweight, which can lead to The individual can become irritable and easily upset and have Sleep can become disrupted and lead to fatigue during the day. Attention and concentration can decrease. Most individuals become obsessed with food and thoughts of food. They may exhibit other obsessions and/or compulsions related to

depression and social withdrawal. 2.
3. 4. 5. 6.

difficulty interacting with others.

food, weight, or body shape that meet the diagnostic criteria for an obsessive compulsive disorder.

Affective (mood) disorders, anxiety disorders, and personality

disorders. Physical Most of the medical complications of anorexia nervosa result from starvation. Few organs are spared the progressive deterioration brought about by anorexia.

1-Heart and circulatory system: Although not life-threatening, an abnormally slow heart rate (bradycardia) and unusually low blood pressure (hypotension). Disturbances in the heart rhythm (arrhythmia). 2-Gastrointestinal complications: Constipation and abdominal pain are the most common symptoms. Changes in liver enzyme levels and overall damage to the liver. 3-The glandular (endocrine) system: Disturbances in the menstrual cycle are frequent, and secondary amenorrhea affects about 90% of adolescent girls with anorexia.. Hormonal imbalances are found in men with anorexia as well. Continual restrictive eating can trick the thyroid to slow down in an attempt to preserve calories. 4-Kidney (renal) function Increased or decreased urination or fatal potassium deficiency. 5-Bone density loss Osteopenia or thinning of the bones with increased risk for fracture may persist later in life. 6-Electrolyte imbalance as anorexics may use a large quantity of laxatives or frequently vomit. 7-Anemia is frequently found in anorexic patients. In addition to having fewer red blood cells and lower numbers of white blood cells. Suppressed immunity and a high risk for infection. 8-Physical symptoms as, low body temperature as well as dry, flaky skin that take on a yellow tinge. Fine, downy hair grows on the face, back, arms, and legs. Despite this new hair growth, loss of hair on the head is not

uncommon. Nails can become brittle. Frequent vomiting can erode dental enamel and eventually lead to tooth loss.

Anorexia may be treated in an outpatient setting or hospitalization. Hospital treatment for an individual with severe weight loss that has impaired organ function, hospital treatment must initially focus on correction of malnutrition, and intravenous feeding or tube feeding that goes past the mouth may be required. A gain of between 1 to 3 pounds per week is a safe and attainable goal when malnutrition must be corrected. Short hospitalization followed by a day treatment program is an effective alternative to longer inpatient programs. Outpatient treatment involving psychological as well as medical intervention.It is common to engage a multidisciplinary treatment team consisting of a medical-care provider, a nutritionist, and a mental-health-care provider.

Bulimia nervosa

Introduction: Bulimia nervosa is an eating disorder in which a person binges and purges. The person may eat a lot of food at once and then try to get rid of the food by vomiting, using laxatives, or sometimes over-exercising. People with bulimia are preoccupied with their weight and body image. Bulimia is associated with depression and other psychiatric disorders and shares symptoms with anorexia nervosa, another major eating disorder. Because many individuals with bulimia

can maintain a normal weight, they are able to keep their condition a secret for years. If not treated, bulimia can lead to nutritional deficiencies and even fatal complications. Causes No one knows what causes bulimia, although there are several theories. Bulimia may have a genetic component, and there is some evidence that women who have a sister or mother with bulimia are at higher risk of developing the condition. Families may put an overemphasis on achievement, or may be overly critical. Psychological factors may also be involved, including having low self-esteem not being able to control impulsive behaviors, and having trouble expressing anger. Some people with bulimia may have a history of sexual abuse. People with bulimia may also experience depression, self-mutilation, substance abuse, and obsessive-compulsive behavior. Cultural pressures to appear thin contribute to the disorder, particularly among dancers and athletes. Signs and Symptoms: Bulimia is often accompanied by the following signs and symptoms:
• • • • • • • • • • • •

Binge eating of high-carbohydrate foods, usually in secret Exercising for hours Eating until you are painfully full Going to the bathroom during meals Loss of control over eating, with guilt and shame Body weight that goes up and down Constipation, diarrhea, nausea, gas, abdominal pain Dehydration Irregular menstruation or lack of menstrual periods Damaged tooth enamel Bad breath Sore throat or mouth sores * Depression

Treatment: The most successful treatment is a combination of psychotherapy, family therapy, and medication. It is important for the person with bulimia to be actively involved in their treatment. Prozac is considered the drug of choice, although some studies suggest that other SSRIs, such as Luvox, may be even more effective. Complementary and Alternative Therapies Psychotherapy is a cornerstone of bulimia treatment. Cognitive behavioral therapy, which teaches you to replace negative thoughts and behaviors with healthy ones, is often used. Mind-body and stressreduction techniques, such as yoga, tai chi, and meditation, may help you become more aware of your body and form a more positive body image Nutrition and Supplements People with bulimia are more likely to have vitamin and mineral deficiencies, which can affect their health. Vitamin deficiencies can contribute to cognitive difficulties such as poor judgment or memory loss. Getting enough vitamins and minerals in your diet or through supplements can correct the problems. Some natural therapies, including dietary supplements, may help general health and well-being. Nutritional tips: • • Avoid caffeine, alcohol, and tobacco. Drink 6 - 8 glasses of filtered water daily.


Use quality protein sources -- such as organic meat and eggs, whey,

and vegetable protein shakes -- as part of a balanced program aimed at gaining muscle mass and preventing wasting. • • Avoid refined sugars, such as candy and soft drinks. A daily multivitamin, containing the antioxidant vitamins A, C, E, the

B-vitamins, and trace minerals, such as magnesium, calcium, zinc, phosphorus, copper, and selenium. • Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil two to three times daily, to help decrease inflammation and improve immunity. Cold-water fish, such as salmon or halibut, are good sources; eat two servings of fish per week. • • Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, 5-hydroxytryptophan (5-HTP), 50 mg two to three times daily, for and muscular support. mood stabilization. Talk with your health care provider if you are on prescription medications before taking 5-HTP. Do not take 5-HTP if you are taking antidepressants. • L-glutamine, 500 - 1,000 mg three times daily, for support of gastrointestinal health and immunity.


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13- Wahl, Richard. Nutrition in the Adolescent. Pediatric Annals Feb. 1999 Venkdeswaran R. Nutrition for Youth. Clinical Family Practice Dec 2000 2(4) 791-822 1415Dietary Guidelines for Americans 2005. Washington, D.C.: U.S. Department Eating Disorders during Adolescence: Nutritional Problems and

of Health and Human Services, U.S. Department of Agriculture, 2005. Interventions Jane Mitchell Rees, PhD, RD, CD