Adolescence is a stage in life that has many biological, cognitive and sociocultural changes. This stage in life is when individuals are most vulnerable and health behaviors play an important role in their future. An adolescent this day in age is bombarded with many behaviors that can affect their future such as; smoking, drug use, and sex. These behaviors can carry immediate and severe consequences but there are other health behaviors such as eating choices and physical activity that can carry risks as well (Lytle, 2002). Lytle explains that there is data that suggests that adolescent's current eating behaviors are putting them at risk for many different diseases later in life.

Some of those diseases include: cardiovascular disease, cancer, osteoporosis, obesity and type 2 diabetes. Adolescents today have decreased physical activity and poor diet habits which makes nutritional issues for adolescents a very important topic that needs to be addressed (Lytle, 2002). Cardiovascular disease begins in childhood. A study completed by Kelley, K rummel, Gonzales, Neal and Fitch examined 279 children. There hypothesis was that children who were at high risk for cardiovascular disease based on their family history would have diets that were different than the low risk children.

The children's height, weight, and total cholesterol were measured and each child filled out a food frequency questionnaire. 23% of the children were at risk for cardiovascular disease and their cholesterol was significantly higher. However intakes of energy, fat, cholesterol and fiber were similar in both the high risk and low risk groups. The researchers concluded that all children whether high risk or low risk need to change their dietary patterns in order to prevent cardiovascular disease. Those at high risk need specific guidelines in order to lower their risk for the disease. Healthcare professionals must promote the healthy benefits of healthy eating habits to both children and their families and finally it is critical that public health research address behavior modification in children (2004).

Diets high in saturated fat, total fat, sodium and low in fiber are associated not only with cardiovascular disease but also some types of cancer. Also diets low in fruits and vegetables are associated with increased risk of some types of cancer. National nutrition surveillance data shows that only 34% of girls and 27% of boys aged 12-19 years fall within the recommended levels for saturated fat, and 36% of girls and 30% of boys aged 12-19 years fall within the recommended levels for total fat. Adolescent diets also exceed the recommended level of 2, 400 mg of sodium. National Health and Nutrition Health Survey (NHANES) III showed the range of sodium aged 12-19 years ranged from 3, 000 mg - 5, 000 mg / day for both girls and boys. The recommended intake of fiber for children aged 2-18 years is their age plus 5 grams per day.

NHANES III data suggest that aged 12-15 year olds would need to increase their fiber intake by 25%-50% and 16-19 year olds would need to double their intakes to meet the recommendations for fiber stated above (Lytle, 2002). Adolescent's high fat, high sodium and low fiber diet not only contribute to increased risk for cardiovascular disease and cancer but also put them at risk to be obese and potential develop type 2 diabetes. Childhood obesity is becoming an epidemic in the United States. The increasing prevalence of childhood obesity has led policy makers to rank it as a critical public health threat. Its rate has doubled for preschool children aged 2-5 years and adolescents aged 12-19 years, and it has tripled for children aged 6-11 years.

This has all occurred in the past 30 years. Childhood obesity involves immediate and long-term risks to physical health. For children born in the United States in the year 2000, the lifetime risk of being diagnosed with type 2 diabetes at some point in their lives is estimated at 30% for boys and 40% for girls if obesity rates level off (Koplan, Liverman & Kraak, 2005). Koplan, Liverman & Kraak also explain how dramatically the Unites States has changed over the past thirty years and how that has impacted the rise of childhood obesity. Family dynamics have changed, now both parents work and they work very long hours. Majority of meals today are not eaten as a family and are usually eaten outside the home.

The school environment has changed; children have many more options at lunchtime including fast food, soda, and candy. Physical activity has decreased. Children's leisure time is spent watching television or playing on the computer. Understanding all of these things and working to modify them is essential for reducing childhood obesity (2005).

Clearly the food choices of adolescents are not consistent with the Dietary Guidelines for Americans. Children's food intake tends to be low in fruits, vegetables and calcium rich foods, and high in both total fat and saturated fat. Children's dietary habits are causing many nutritional issues that can affect their health in many negative ways. In order to develop effective nutrition interventions to change eating behaviors and ward off disease, factors influencing adolescent eating behaviors need to be understood. Story, Neumark-Sztainer & French discuss Social Cognitive Theory (SCT). "SCT provides a useful theoretical framework for understanding and describing the multiple influences that have an impact on the food behaviors of adolescence.

In SCT, behavior is explained in terms of a 3-way, dynamic and reciprocal interaction between personal factors, environmental influences, and behavior. Key concepts of SCT are self efficacy (self confidence to change a behavior), observational learning (modeling), reciprocal determinism (bidirectional influences), behavioral capability (knowledge and skills to change the behavior), expectations (beliefs about likely results of the action), functional meanings (personal meaning attached to the behavior), and reinforcement (response to a person's behavior that increases or decreases the chances of its recurrence) " (2002). Ecological perspective is another model used for understanding factors influencing eating behavior. Ecological perspective looks at the connections between people and their environments. Reciprocal determinism is central in both SCT and the ecological perspective.

Reciprocal determinism means that both the behavior and the environment influence each other in both directions (Story, Neumark-Sztainer & French, 2002). Adolescent eating behavior has multiple levels of influence. There are four broad levels of influence, they are as follows; individual influences (intra personal), social environmental influences (interpersonal), physical environmental influences (community settings) and macro system influences (societal) (Story, Neumark-Sztainer & French, 2002). The following portion of this paper will examine the four levels of influence.

Story, Neumark-Sztainer & French explain how psychosocial, biological and lifestyle factors are apart of individual influences. Psychosocial factors like attitudes, beliefs, knowledge, self-efficacy, taste and food preferences, biological factors like hunger and life-style factors like cost, time demands and convenience are all considered individual factors that effect eating behaviors (2002). Social environmental influences include family and friends. Family not only provides the food but also shapes a child's food attitude, preference, values and habits.

As stated before, United States families have dramatically changed over the past thirty years. Family structure is different, both parents are working, both children and parents are too busy for meals at home. Family meals no longer exist and parents can not control what their child is eating outside of the home. Friends influence adolescent behavior in all aspects. Adolescents seek out approval among their peers. There are however not many studies that have found a strong association between eating behaviors and peer influence (Story, Neumark-Sztainer & French, 2002).

Another influence that effect adolescent-eating behavior is the physical environment (community setting). One third of all eating done by adolescents is outside of the home. Children these days eat majority of their meals at school, fast food restaurants, from vending machines, and convenience stores. Macro system influence (Societal) is the last of the four influences. Factors within the larger society, which can affect adolescent eating behavior, include the media, cultural norms, social norms, food production and distribution systems, and food accessibility and availability. Adolescents are consumers.

Marketers have now targeted adolescents specifically. Adolescents spend about 140 billion dollars a year, 94 billion is money they have earned themselves. Boys spend $59. 00 a week and girls spend $53. 00 a week and 15% of the money spent is on fast foods and snacks.

Adolescents also influence their parents spending. It is estimated that adolescents spent 47 billion of family money and 19. 6 billion in grocery money spent was influenced by adolescent's preferences. Marketers see adolescents as future adult spenders and really work to maintain brand loyalty (Story, Neumark-Sztainer & French, 2002). Clearly there are a multiple influences on adolescent eating behavior. An understanding of how the four levels of influence interact and affect adolescent eating behaviors is needed for the development of effective nutrition interventions.

Interventions addressing factors at the different levels of influence are needed to improve eating behaviors of youth. This is a challenge that will require multifaceted, community wide efforts. Through community outreach, advocacy work, partnerships with food / restaurant industries, media groups, government programs, and school districts efforts can be made to positively influence adolescent eating behavior. Knowing the all the influences adolescents have today, where does a dietitian begin when addressing eating behaviors of adolescents and their nutritional status? An article written by Jamie Stang, PhD, MPH, RD discusses the assessment of nutritional status and motivation to make behavior changes among adolescents. Nutritional screening, establishing a relationship, setting an agenda, assessment of growth and development, assessment of dietary intake and physical activity, in-depth dietary assessment and assessing motivation to make behavior changes are all aspects a comprehensive, effective counseling session with a child (2002). A nutritional screen should be completed on the initial visit and should involve a complete nutritional profile of the adolescent.

A review of available medical, laboratory, psychosocial, and socioeconomic assessments should be completed and provide relevant information on physiological, psychological, and economic factors that may influence nutrient needs and dietary adequacy among the adolescent population. Second a relationship needs to be established. Stang recommends that the counselor introduces his / her self and explains why they are meeting. Open-ended questions should be used giving the adolescent adequate time to respond. Also working to normalize the adolescent's feelings of apprehension aids in opening the lines of communication. The third step is to set an agenda.

Discuss with the adolescent how long they will be talking and what they will be discussing during the session. Also asking the adolescent what they expect from the session is beneficial and letting them know that they can address any topic discussed at any point during the session is important. Stang suggests that the agenda is mutually agreed upon and permission is granted to proceed. The fourth step involves obtaining an accurate assessment of growth and development.

Looking at the client's height and weight at every session is very important there is a rapid rate of growth and development during this period of time. Initial assessment of dietary intake and physical activity is the fifth step. Physical activity should be briefly discussed to determine whether or not further counseling is appropriate on exercise. Asking questions like, "How many days of the week do you participate in light exercise such as walking, and rigorous exercise such as a competitive sport?" will provide the counselor with the adolescent level of physical activity. Also inquiring about the amount of time the client watches television or spends on the internet is good information for the counselor. This information can be used during educational and counseling sessions for goal setting and determining behavior changes.

The initial dietary assessment involves gathering a large amount of data to determine eating patterns and to identify nutrition risk indicators. Stang lists many questions that can be used to characterize usual eating patterns of adolescents and to determine the presence of nutrition risk indicators. Here is a list of a few: . Number of meals and snacks eaten n weekdays and weekends. Location where meals and snacks are eaten. Determine the kind of meals eaten at school, a la carte or program meals.

The number of family meal times, whether the adolescent eats alone or with peers. Food preferences. Determine the adolescent's ability to purchase and prepare food. Note the number of servings of fruits and vegetables consumed in a week. Determine ethnic or religious food preferences, food allergies or in tolerances Bullets listed above are just a few questions that can be asked in order to obtain information about an adolescent's eating behaviors. Brief, informal, dietary assessment questionnaires that target specific behaviors can also be useful for an initial nutrition screening.

These can be done quickly to determine whether an adolescent needs further nutritional counseling or to determine the need to address certain food components such as fat, sodium or calcium (2002). An in-depth nutritional assessment is completed on adolescents with a nutritional related health risk. It should involve a full medical history review, psychosocial development and evaluation of laboratory data. A detailed dietary assessment is also obtained and has four main components - 24 hour recall (A 1), food frequency questionnaire (A 2), food record (A 3) and diet history (A 4). Also Stang provides a helpful table that lists the strengths, limitations and applications of the four main components of a detailed dietary assessment. After obtaining the adolescent's diet history with one of the four components, the data should be analyzed with a nutrient analysis program.

The results should be compared with the recommended dietary intakes of the adolescent and Stang suggests allowing the client to view the results of his / her diet with the recommended dietary intakes to see how they compare. His gives adolescents' empowerment builds rapport between client and counselor and increases the likelihood that they will be motivated to make dietary changes (2002). Once the counseling session has begun with an adolescent it is important to evaluate the motivation to make behavior changes. The adolescent at this point has already compared his / her diet with the recommendations and has identified what areas they need to improve.

At this time the adolescent should prioritize one or two areas they are willing to work on. Once that is decided upon the counselor must make suggestions as to how the adolescent can achieve the goal. For example if the adolescent is overweight recommendations can be made on ways to lose weight such as increasing physical activity, decreasing portion sizes, making healthier food choices. The adolescent should be asked what changes would work for them and focus in on one change. This way the client is making the decisions and is not being told what to do. Also with the client choosing it shows that they want to change and is willing to work on one goal.

Stang suggests that the adolescent rates his / her motivation to make the behavioral change on a scale of 0-10, 0 meaning not willing to change and 10 meaning very willing to change. The counselor should than ask why he / she choose that number and not a higher number. The adolescent is than given the opportunity to voice some potential barriers to change. This should be discussed for every behavior change the adolescent decides to work on. An intervention such as nutrition counseling and education can be tailored to the level of change the adolescent is comfortable with (2002). Fit Family Fit Kids is a joint initiative of the Department of Health and Human Services' Centers for Disease Control and Prevention (CDC) and Gruner & Jahr USA Publishing.

Their goal is to help raise awareness and provide long term strategies to help parents of kids ages 9-13 in their efforts to improve their family's physical activity and nutrition habits (xxxx xxx, ). Every month in Fitness magazine has an update on the current family in. In the March issue of Fitness magazine the Schall family was featured in their six and last month. Donna and Roth Schall agreed in October 2004 to change their sedentary ways and increase their physical activity. Their ultimate goal was 60 minutes a day for Roth (teen-age son) and 30 minutes a day for Donna (busy single mom). The Schall's motivation to make behavior changes is clear.

Both mother and child agreed to be followed by Fitness magazine and have their stories told to millions of readers. Keri Klik, an exercise physiologist, who helped the Schall's with monthly strategies to meet their goals, followed them for the next 6 months. Each month Keri gave the Schall family key strategies for success. Strategies started small like walking two nights a week together, watching less television and decreasing soda intake. By month 3 the family was including more sports like cycling, tennis and baseball in their routine also they have started circuit weight training together and have been drinking more water. By month six the Schall's have consistently included exercise in their daily life and love it.

They had one goal as a family and that was to increase physical activity, now the Schall's are interested in working on their diet. They had made a consistent effort to eat a healthy breakfast every morning and include more healthy meals and snacks in their day. As Keri stated, "they now see the big picture and are motivated to continue their healthy lifestyle." Fit Family Fit Kids has shown how making small behavior changes in one families life can make big changes in both parent's and children's health (Fitness, 2005).