European Journal of Clinical Nutrition (2000) 54, Suppl 1, S7±S10

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Adolescence: macronutrient needs

M Giovannini, C Agostoni*, M GiannõÂ, L Bernardo and E Riva

Department of Pediatrics, San Paolo Hospital, Via A. di Rudini 8, 20142 Milano, Italy

Dietary needs during adolescence lack speci®c de®nitions, and most evidence is derived from indirect
indications. The data on dietary needs for energy and proteins are mainly extrapolated from subjects in other
age-classes. Lipids and carbohydrates are being progressively considered for preventive purposes since the
qualitative distribution of saturated and unsaturated fats and slowly and rapidly absorbed carbohydrates,
respectively, seems to be associated with metabolic index predictors of degenerative disorders in later stages
of life. The recent results of multicentric autoptic studies in young people from the US indicate that the
lipoprotein status of the second decade of life is associated with the ®rst raised arterial lesions in the third decade.
The evidence of these links needs further con®rmation from ongoing surveys. We must recognize that
adolescence is a critical period of life, and food fads may deeply change the dietary habits acquired within
the familiar group. As nutritionists, we may suggest that all adolescents should be supplied with nutritional
support in terms of education, maybe at school, to improve their knowledge of nutrition.
Descriptors: adolescence; dietary habits; dietary recommendations; prevention
European Journal of Clinical Nutrition (2000) 54, Suppl 1, S7±S10

Introduction
Adolescence is an intense anabolic period. Indicated diet-
ary allowances for macronutrients in this period should
cover both growth processes and preventive purposes. In
this perspective, the quality of the dietary fats and carbo-
hydrates seems relevant to the early prevention of cardio-
vascular and acquired metabolic disorders.
Energy needs
Energy needs are de®ned as the dietary intake necessary to
balance the energy employed for internal work, external
work, growth and repair of tissues. Recommended energy
intakes should include individual variation, but also repre-
sent average requirements. Current recommendations are
generally based on estimates of energy expenditure rather
than energy intake.
Anabolic activity is intense during puberty since,
besides the appreciable increases in anthropometric indices
(weight and height), there is an increase in the lean mass,
changes in the amount and distribution of fatty tissue and
development of internal organs and systems (Gong &
Heald, 1994).
The weight deposition through adolescence contributes
50% to ®nal adult weight, and energy requirements are
closely correlated to the rapid increase of fat-free mass. The
linear spurt during adolescence contributes about 15% to
®nal adult height, kJ=cm height might also represent a way
of calculating the individual energy requirements of adole-
scents (Pellett, 1990). Males gain more lean mass, which
has a higher metabolic activity than adipose tissue, while
females deposit more fatty mass. Ideal requirements should
include the timing of the pubertal growth spurt (with the
wide differences in age at which puberty starts) and the
*Correspondence: C Agostoni, Department of Pediatrics, San Paolo
Hospital, Via A. di Rudini 8, 20142 Milano, Italy.
E-mail: agostoc@tin.it
Contributors: All the authors contributed to the writing of the manuscript.
increase in lean body mass rather than weight, and should
allow for possible catch up growth if growth through
childhood has not been optimal. As an example of energy
requirements, in the Italian Dietary Allowances (SINU
(Italian Society of Human Nutrition), 1996) the energy
requirements (Table 1 ± 3) are calculated by means of the
factorial method, as for adults, and are expressed as the sum
of basal metabolism (according to Scho®eld et al, 1985),
energy cost of physical activity, thermogenesis induced by
dietary intake and 21 kJ per gram of new tissue deposition.
In this respect, basal metabolism represents the energy
needed by all the anabolic and catabolic biochemical
reactions taking place in the body. The energy cost,
expressed as physical activity level, depends on the kind,
frequency and intensity of the single activities performed
by the subject. The thermogenesis induced by dietary
intake represents the increment of the energy requirements
following the ingestion of foods.
Protein needs
The question of the ideal protein intakes at various ages is
still matter of investigation, and the requirements are
periodically revised on the basis of the new data on the
catabolic and anabolic turnover of the nitrogenous com-
pounds (Clugston et al, 1996). Proteins in the body undergo
a series of metabolic reactions, which include demolition
and reutilization, that is, the so-called protein turnover. The
most frequent method to estimate protein needs is through
the nitrogen balance method (WHO, 1985). It determines
the minimum amount of dietary proteins needed to keep
healthy, non-pregnant, non-lactating adults in nitrogenous
balance.
Protein needs during adolescence are dictated not only
by the maintainance processes but also by the growth of
new tissues, considering the individual variations. Data on
either of these determinants of requirements are lacking in
adolescents and have been interpolated from studies on
infants and adults. It is well known that during growth the
 Adolescence: macronutrient needs
S8
Table 1 Basal metabolism (kJ) calculated with the Scho®eld et al (1985)
method. Subjects were 10 ± 17 y old (SINU, 1996)
Males Females
16.2 kg body weight ‡ 8.36 kg body weight ‡
136 m height ‡ 466 m height ‡
516 201
Table 2 Energy needs (kJ) corrected for physical activity level (PAL),
expressed as a multiple of the basal metabolism (SINU, 1996)
PAL Males
Mild 1.55
Medium 1.78
Heavy 2.10
Table 3 Range of energy needs of adolescents (kJ=day) by sex and age
(SINU, 1996)
Age (y) Males
11.5 8334 ± 9795
14.5 9518 ± 11,683
17.5 10,514 ± 13,439
Table 4 Protein needs (g=kg body weight per day, after correction for
protein quality of foods ˆ 0.79) (SINU, 1996)
Age Males
11.5 1.24
14.5 1.22
17.5 1.09
ef®ciency of the utilization rate of nitrogen increases with
the rate of tissue deposition, and that the energy=protein
ratio represents the biochemical limiting step for the
optimal anabolism of the nitrogenous sources. On the
other hand, we do not know at which part the ratio becomes
the `best' for both the short-term outcome (i.e. growth
processes) and the long-term outcome (i.e. the prevention
of chronic-degenerative disorders).
To indicate protein needs for an adolescent, physiologic
age should be considered rather than chronologic age
because of the wide differences in the age at which puberty
starts. Protein synthesis is an energy-expensive process and
the caloric intake must be adequate. Not only does nitrogen
balance become more negative as energy is reduced, but it
also becomes more favourable when the energy intake is
increased. Moreover, besides the physiologic state of the
individual and the caloric intake, other factors in¯uencing
protein metabolism in the body include dietary intake,
amino acid composition of the dietary protein (Table 4),
nutritional status and any disease state (SINU (Italian
Society of Human Nutrition), 1996).
The proportion of total energy represented by proteins
should remain fairly constant, between 12% and 14%,
throughout childhood and adolescence. Surveys on dietary
habits in this period show that the average intakes of
protein in adolescence are in general above the recom-
mended levels (Agostoni et al, 1994). At each level of
protein intake a new nitrogen balance is reached. Different
states of nitrogen balance may be favourable or not,
depending on the measures of outcome we want to con-
European Journal of Clinical Nutrition
M Giovannini et al
sider. For example, it has been suggested that an excessive
intake of proteins may cause a mobilization of calcium
from bones. This mechanism could have unfavourable
effects on the mineralization of bones and the vascular
tone, thus contributing to the development of osteoporosis
and vascular hypertension (Karanja & McCarron, 1986,
Agostoni et al, 1994). At present, it is still unknown what
the best protein intake is during adolescence, as different
nitrogen balances have theoretical advantages and disad-
vantages in relation to both short- and long-term outcomes.
Consistently with a growing trend, the requirements of
Females single amino acids more than the whole protein needs are
currently indicated as more relevant to their functional
1.56 roles (Young & Pellett, 1990).
1.64
1.82
Fat needs
The common recommended allowances for dietary lipids
Females and cholesterol during adolescence by most general Com-
mittees and Institutions can be summarized as follows:
7271 ± 8564
7794 ± 9602  for saturated fatty acids, < 10% of total calories;
8120 ± 10,079  for total fat, no more than 30% and no less than 20% of
total calories;
 cholesterol, < 300 mg per day.
The main reason for these recommendations lies in the
general agreement towards the prevention of chronic
Females degenerative disorders of the cardiovascular system, begin-
1.24 ning in childhood (American Academy of Pediatrics,
1.14 1998). Concern has been raised about the safety of choles-
1.01 terol-lowering diets in children, particularly during years of
intense growth. The concern includes possible de®ciencies
in growth and nutrient adequacy, particularly iron intake,
and potential adverse psychological effects. Recent studies
have now documented more in detail the progression from
high blood lipid levels to high-risk conditions for chronic-
degenerative disorders throughout childhood and adoles-
cence. In 1985 a group of investigators organized the
Pathobiological Determinants of Atherosclerosis in Youth
(PDAY) Study in order to obtain more extensive data on
the relationship of risk factors to atherosclerotic lesions in
youth (Wissler RW, 1991). At post-mortem examination in
young adults aged 15 ± 19 y (primarily traumatic deaths),
fatty streaks occupy about 25% of the aortic intima in both
the thoracic and abdominal aorta. The lipoprotein pro®le
begins to affect raised lesions in the 20 ± 24 y age group
(Mc Gill et al, 1997). Fatty streaks and raised lesions are
represented more in persons with unfavourable lipoprotein
pro®les (highest third of VLDL ‡ LDL blood cholesterol,
lowest third of HDL blood cholesterol) than in persons
with favourable lipoprotein pro®les (lowest third of
VLDL ‡ LDL blood cholesterol concentration, highest
third of HDL blood cholesterol concentration). Thus, we
now have evidence that serum lipid concentrations, smok-
ing, obesity and hyperglycemia are closely associated with
fatty acid streaks in the second decade of life. The same
risk factors, along with hypertension, are associated with
raised lesions in the third decade of life. These results
indicate that the long-term prevention of coronary heart
disease should begin in childhood with the control of risk
factors for coronary heart disease in order to limit the
extent of juvenile fatty streaks and, more critically, to
prevent or delay their progression to raised lesions in the

years immediately after adolescence. Indeed another autop-
tic study has con®rmed that, as the number of cardiovas-
cular risk factors increases, so does the severity of
asymptomatic coronary and aortic atherosclerosis in
young people (Berenson et al, 1998).
Doubts about the possibility of an early intervention to
correct lipid unbalances has been raised by con¯icting
observations on the `tracking' of blood high cholesterol
levels through the adult age. Accordingly, in the Muscatine
Study a substantial number of children with high blood
cholesterol levels became adults with desirable cholesterol
levels without intervention (Lauer & Clarke, 1990). On the
other hand, among 2446 subjects initially examined at ages
8 ± 18 y and re-examined as young adults at ages 20 ± 25 y
or 26 ± 30 y, of children found to have cholesterol levels
greater than or equal to the 90th percentile for their age and
gender on a single measurement, 43% remained above the
90th percentile, 62% remained above the 75th percentile
and 81% remained above the 50th percentile (Lauer et al,
1989).
Regarding the ef®cacy of blood lipid-lowering diets
during adolescence, we have now the contribution of a
recent survey from US (The Writing Group for the DISC
Collaborative Research Group, 1995). In this study the
ef®cacy of diets lowering fat in prepubertal children with
blood LDL-cholesterol ˆ 80 ± 98th percentiles for age and
sex has been tested through a 3 y follow-up. An interven-
tion group received a diet with 28% calories from total fat,
10% calories from saturated fat and 95 mg per day choles-
terol and was compared with a group that consumed 33 ±
34% calories as total fat, 12.7% calories as saturated fat and
112 mg cholesterol per day. The authors observed that a
dietary intervention is effective in achieving a modest
lowering of blood LDL-Chol ( 0.08 mmol=l, 95% CI
0.15, 0.01), while maintaining adequate growth and
psychological well-being in the intervention group.
As evidenced by these studies, US pediatricians are
convinced of the validity of a low-lipid, low-saturated fat
diet for preventive purposes. In Southern European Coun-
tries, where a favourable association between the consump-
tion of olive oil and a low mortality rate for cardiovascular
disorders has been observed, more emphasis has been
placed on the role of a monounsaturated fat-rich diet,
even if it may involve a total fat content in the diet
higher than 30% energy (Grundy, 1989; Keys, 1995).
Indeed, olive oil, the richest source of monounsaturated
fats in Southern Europe, also includes minor constituents
with several biologic activities that may contribute to the
lower incidence of coronary heart disease in the Mediter-
ranean area (Visioli & Galli, 1998).
In the Italian context, we have followed for 12 months
a sample of prepubertal, hypercholesterolemic children
(entry criteria: blood LDL cholesterol  2.85 mmol=l)
through a familial dietary counselling at 0, 6 and 12
months aimed at increasing the variety of vegetable foods
and ®sh to favourably modify the intake of animal proteins
and unsaturated fats (Decarlis et al, 1998). The children
were assessed at 0 and 12 months with a validated food
frequency questionnaire and by blood sampling for total
cholesterol, HDL-cholesterol and triglycerides (enzymatic
methods) while LDL-cholesterol was derived with the
Friedewald formula. Growth indices were compared with
the NCHS-WHO z-scores. Thirty-two subjects (17 females
and 15 males, mean age 11.5, range 10 ± 14 y, mean LDL-
cholesterol 4.26, s.d. 1.13, mmol=l) entered the study. At
Adolescence: macronutrient needs
M Giovannini et al
S9
entry the diet was mildly hypercaloric and the average fat
intake was 28% energy with saturated fats at 9.0%. After 12
months, the children were reassessed and the following
signi®cant changes (P < 0.05) were found (mean value):
 41 kJ energy per kg body weight per day;
 0.37 dietary animal=vegetal protein ratio;
 0.54 mmol=l blood total cholesterol;
 0.49 mmol=l blood LDL-cholesterol.
No changes were observed for blood HDL-chol and for
weight and length z-scores. No subject showed any major
change of the puberal stage during the follow-up. We
conclude that a qualitative dietary counselling results in
an increased intake of vegetables in hypercholesterolemic
children and favourably modi®es the blood lipid pro®le
without any adverse effects on growth.
Summarizing, there is evidence that, in adolescence,
fatty streaks take place in the vessel walls, while their pro-
gression to and=or substitution with complicated plaques
are associated positively with blood LDL- and VLDL-
cholesterol levels and negatively with HDL-cholesterol
levels. The dietary intake of speci®c saturated fat and
cholesterol are the primary determinants of LDL-choles-
terol levels. The dietary advice on the recommended lipid
quality and quantity needs to be reemphasized for adoles-
cents and qualitative dietary changes may favourably
modify the blood lipid pro®le while improving the balance
of animal and vegetable foods.
Carbohydrate needs
The requirements for dietary carbohydrates are derived by
subtracting the energy equivalents of proteins and fats from
the recommended daily caloric intake. Within this estimate
(55 ± 60% of the energy estimate) an ideal combination of
sugars, slowly absorbed carbohydrates and ®ber is recom-
mended for preventive strategies. Indeed the new strategy
for the prevention of chronic degenerative disorders in
adults has put the dietary carbohydrate estimate on the
same level as the lipid quality (Kasim-Karakas, 1998). The
role of the so-called `non-digestible carbohydrates' has
been emphasized for healthy functional and metabolic
effects such as the establishment of a favourable colonic
¯ora, the improvement of the blood glucose ± insulin axis
and a decrease of blood lipid levels for the prevention of
colon cancer, diabetes and cardiovascular disorders respec-
tively (Jenkins, 1988). With the term non-digestible carbo-
hydrates we actually include ®ber, resistant starch and the
non-metabolizable fructo-oligosaccharides. In other terms,
the functional concept of ®ber may be extended to all non-
digestible carbohydrates, that is, all the molecules unable to
undergo enzymatic digestion in the small bowel for bio-
chemical and=or physical characteristics. The main effects
of the presentation of these compunds to the large bowel
are evident on the resident ¯ora, with the selection and
prevalence of strains contrasting the establishment of
enteropathic bacteria and producing biologically active
compounds (such as the short-chain fatty acids butyrate
and propionate; Cummings & Englist, 1987).
Simple carbohydrates (also de®ned as sugars) should
supply no more than 10 ± 12% the daily energy allowance.
Theoretically, this limited supply should help in maintain-
ing a more physiological release of insulin into the blood-
European Journal of Clinical Nutrition
 Adolescence: macronutrient needs
M Giovannini et al
S10
stream (thus maintaining the glucose sensitivity within an
acceptable range) and to prevent also dental caries.
There is no agreement on the ideal recommended
intakes of ®ber during childhood and adolescence, while
for the adult population the value of 30 g per day is
generally indicated. It has been suggested that a regular
®ber intake may not be necessary in the ®rst year of life and
a limit of 0.5 g ®ber per kg=day is recommended only after
the second year (Agostoni et al, 1995). The American
Health Fundation proposed in 1994 the limit of `age plus
®ve' in grams=®ber per day during childhood (Williams
et al, 1995). A pitfall in these dietary recommendations lies
in the lack of any indication of the type of `non-digestible
carbohydrates' that should be included within the term
`®ber'. In other words, it is not known whether an ideal
proportion of `soluble' and `insoluble' ®ber should be
recommended and to what extent this recommendation
should be directed towards healthy subjects and=or adoles-
cents affected by dysmetabolic conditions.
Conclusions
Dietary needs during adolescence still lack speci®c de®ni-
tions, and most evidence is derived from indirect indica-
tions. The data on dietary needs of energy and proteins are
mainly extrapolated from subjects in other age-classes.
Lipids and carbohydrates are being progressively consid-
ered for preventive purposes since the qualitative distribu-
tion of saturated and unsaturated fats and slowly and
rapidly absorbed carbohydrates respectively seems to be
associated with metabolic index predictors of degenerative
disorders in later stages of life. The evidence of these links
is recent and we now wait for more information from
ongoing surveys. We must recognize that adolescence is
a critical period of life, and food fads may deeply change
the dietary habits acquired within the familiar group. As
nutritionists, we suggest that nutritional support in terms of
education, maybe at school, should be supplied to all
adolescents to improve their knowledge of nutrition. Diet-
ary counselling aimed at increasing the consumption of
vegetables, legumes, fruit and nuts may lead to a better
balance of the protein=energy ratio and the saturated=
unsaturated fat ratio, while increasing the supply of
slowly absorbed carbohydrates and ®ber.
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