Teen girls & their health.

In the past six months, adolescent girls have become the new media darlings. But between a cover story in Newsweek magazine on "gamma girls," (1) ("truly nice" adolescent girls are apparently so unique they require their own moniker), a section-front article in USA Today headlined "Caught in the Catty Corner" (2) and the release of such books as Queen Bees and Wannabes: Helping Your Daughter Survive Cliques, Gossip, Boyfriends, and Other Realities of Adolescence (Crown Publishers, 2002), it's easy to assume that today's teenage girls navigate such an obstacle course of sex, cruelty and self-esteem issues it's miraculous any emerge with their physical and emotional health intact.

But if you ask the focus of all this attention -- the adolescent girl herself (in this case, a group of middle-class teens from suburban Maryland) -- what it's like to be her, you hear a somewhat different story.

* From Megan *, 15, a high school junior: "It's frustrating, hopeful, stressful, amusing, loving and wonderfully fun."

* Or Britney *, 13, an eighth grader: "(It) totally sucks sometimes but it can also be so awesome.

* Or Pammy *, 13, an eighth grader: "You're trusted more and people depend on you to excel in school and be respectful."

And their health? "I view my health as OK," pretty much summed it up.

In general, adolescent girls' health is OK. "Girls come into adolescence healthy and it's our job -- both as parents and clinicians -- to keep them that way," says Lydia A. Shrier, MD, MPH, adolescent medicine specialist, Children's Hospital Boston and assistant professor of pediatrics, Harvard Medical School.

That can be a challenge. For teenage girls face numerous health risks -- many the result of the world they live in, others linked to their own gender. For instance, teenage girls are much more likely to contract certain sexually transmitted diseases than boys because of the way their reproductive system develops. (3) And, compared with boys of the same age, studies find teenage girls experience lower grades and diminished academic achievement compared to when they were younger, are more anxious and stressed, express more dissatisfaction and distress about their bodies and looks, suffer from increased depression, lower self-esteem, have a greater number of eating disorders and attempt suicide more frequently. (4) They're also significantly more likely to be physically or sexually abused by someone they're dating. (5)

Suddenly, those headlines and book titles begin to make sense.

Moving from Childhood to Adulthood

"The major issue from which everything else flows is the whole transition from being a child to being an adult and all the attendant changes that go along with that," says Alain Joffe, MD, associate professor of pediatrics at Johns Hopkins University in Baltimore.

For instance, adolescent girls have to contend with significant physical changes, including the development of breasts, the widening of their pelvis and an increase in their percentage of body fat. "At a time when the message is be thin, be thin, be thin, girls have to come to grips with a body that is not consistent with the standards displayed in the media and teen magazines and movies," says Dr. Joffe. That can often lead to body dissatisfaction and eating disorders. In fact, while boys are more likely than girls to be overweight, girls are more likely to think they're overweight. (6)

Take Debby *, a 13-year-old eighth grader. She hates how she looks because, she says, she's overweight. Yet at 5'6-1/2" and 152 pounds, Debby has a body mass index (BMI) of 24.5 -- within the government's "normal" range. (7) (Health care professionals use the BMI to determine how weight correlates with height and if it's within a healthy range. BMI-for-age in children and adolescents can be approximated by dividing weight in pounds by height in inches, then dividing that result by height in inches again and multiplying by 703.) (8)

Emotional Minefield

As teenagers grapple with adolescent complexities, girls are more likely than boys to turn their worries and anxieties inward, says Dr. Joffe. There they fester, resulting in high rates of depression. In fact, girls are twice as likely as boys to be depressed, and nearly twice as likely as boys to consider suicide. (6) Boys, on the other hand, externalize their behavior, exhibiting more interpersonal violence and substance abuse, including alcohol and tobacco use, when they're depressed than girls, says Adelaide Robb, MD, medical director of the Adolescent Inpatient Psychiatry Unit at the Children's National Medical Center in Washington, DC.

"I've definitely seen more mental health issues with teenage girls these days," says school health services coordinator Donnese Kern, RN-CS, MSN, NCSN, NP, who has been a school nurse for 32 years in Big Stone Gap in western Virginia. "I see more depression and panic disorders," she says.

What's still not clear is why the numbers of girls -- and boys -- with depression is rising. One reason may be that teenage girls are just better these days at articulating how they feel, says Ms. Kern. "One thing I hear from a lot of kids is that they think they should handle their problems on their own," says Dr. Robb.

It isn't easy talking to your parents, admits Debby. Britney agrees. "I don't really talk to my parents about that kind of stuff (feelings, worries and fears)," she says. "It's awkward." Quite often, says Ms. Kern, the girls turn to other adults in their lives they can trust, like school nurses. "We're beginning to work much more with these mental health issues," she says.

That means working on self-esteem issues as well, since self-esteem and depression are tightly intertwined. The connection, says Dr. Robb, may explain some of the gender differences in depression rates between girls and boys, since teenage girls are more likely to battle with self-esteem issues than boys.(4)

This can be dangerous, since self-esteem (or the lack thereof) is linked to risk-taking behavior. The connection is huge, says Elizabeth L. Schroeder, MD, director of the Division of Pediatric and Adolescent Gynecology at Allegheny General Hospital in Pittsburgh. "The girls with high self-esteem in general are much less likely to be sexually active, smoking, drinking, doing drugs."

To help your daughter maintain strong self-esteem, adolescent experts have this advice: Be there. "Be involved in her life, talk to her, support her. Encourage her to follow her dream," says Dr. Schroeder. "Kids do want their parents to talk to them and pay attention to them, not just when they've done something wonderful or terrible," says Dr. Robb.

Growing Problem of Growing Girls

Ask a handful of adolescent health specialists about the major health issues for adolescent girls and, while you get a handful of answers, they all agree on one: Obesity. It's kind of ironic, they admit, since so much attention is paid to eating disorders like anorexia and bulimia. But obesity is also an eating disorder, says Dr. Shrier. And while just one percent of adolescent girls are anorexic, she says, nearly 25 percent are overweight -- or have a BMI for their age in the 95th percentile or higher.(8)

"It's a major epidemic," agrees Charles E. Irwin, Jr., MD, president of the Society for Adolescent Medicine and director of the Division of Adolescent Medicine at the University of California, San Francisco. And, given the lifelong consequences of obesity -- diabetes, heart disease, cancer -- it's one that presents the greatest risk to a young girl's adult health. The reason for the epidemic is multifaceted, say adolescent health experts. For one, teens exercise less, eat more and eat more high-calorie foods. In 1994 to 1996, for example, the average teenager got one-fifth of her calories from refined sugars.(9) Sixteen years ago, U.S. teenagers consumed almost twice as much milk as soft drinks; today, that figure has flipped. (10) And for every additional soda an adolescent drinks, there's a 60 percent greater chance of obesity. (11) Additionally, girls from low-income families have an even higher risk of obesity because of the poor nutrition they receive, the experts note.

"As homes get busier and busier and parents have less time to cook, there's more take out, which is higher in fat and less nutritional than meals cooked at home," says Dr. Joffe. (For more on getting your daughter to eat healthfully, see Lifestyle Corner, p. 8.)

Playing Catch Up - In a Dangerous Way

For all their differences from boys, adolescent girls are becoming remarkably similar in one disturbing area: They're catching up to and surpassing boys when it comes to risky behavior. In the year 2000, girls aged 12 to 17 were more likely to smoke cigarettes (14.1 percent) than boys (12.8 percent). They're also just as likely as boys to use alcohol, (12) with half of all high school girls saying they drink. Girls are also learning to drink like boys, with one-fourth reporting they binged (had five or more drinks on one occasion) in a 30-day period in 1999. (13) Although boys still "out-binged" girls overall, that difference disappears among younger girls, with ninth-grade girls now consuming alcohol and binging at rates equal to boys. (14)

"It's not viewed as weird anymore for girls to drink and do drugs," says Dr. Irwin. "It used to be a boy thing, it's no longer a boy thing. Most of the problems associated with alcohol use in our clinical setting are with girls. This is very different than a decade ago." That should be frightening news to any parent of a teenage girl, since girls who are heavy drinkers are five times more likely to engage in sexual intercourse and a third less likely to use condoms, and are more likely to suffer depression and attempt suicide. (13)

And the girls we talked to? Most admit to some experimenting. "I used to do drugs, but have been clean for a year and a half," says Megan **, 15. Mimi**, 12, says she drinks "a little," but doesn't worry about the health effects.

On the other side of the fence, however, are girls like Christy*, 15, who, when we asked about drinking, smoking, drugs and sex, said: "I don't do any of those and I never thought of doing them, either. Not only do I worry about the physical and mental repercussions of this, but also of my morals, and how it will affect my future."

To get your teenage daughter through adolescence with her mind and body intact, says Dr. Shrier, parents have to start long before puberty. "You have to practice the concept of preventive maintenance, of putting oneself and one's health in a position of primary importance so that when a kid is faced with decisions about risky behaviors, they consider their health first."

* Not her real name

** Not their real names

References

(1.) Meet the Gamma Girls. Newsweek. June 3, 2002.

(2.) Hellmich N., Caught in the Catty Corner; Experts call it 'relational aggression' but adolescent girls say peers are just mean. USA Today, April 9, 2002.

(3.) Sexually Transmitted Diseases and Women's Health, National Women's Health Resource Center Health Report, June 2002.

(4.) A New Look at Adolescent Girls: Strengths and Stresses, report from the American Psychological Association, 1998, www.apa.org

(5.) Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. JAMA. 2001 Aug 1;286(5):572-9.

(6.) Youth Risk Behavior Surveillance, United States, 2001. U.S. Centers for Disease Control and Prevention (CDC). www.cdc.gov

(7.) Based on calculation from www. nhlbi.nih.gov

(8.) CDC, Body Mass Index for Children, www.cdc.gov

(9.) U.S. Department of Agriculture, Economic Research Service. Food Consumption, Prices, and Expenditures, 1970-1997, p.76. (1999). Sugar and Sweetener, Publication 555-225, May 1999, p.87 (Table 59). www.cspinet.org

(10.) U.S. Department of Agriculture, Nationwide Food Consumption Survey, 1977-78, Tables A1.2-1; 1.7-1 and -2. Continuing Survey of Food Intakes of Individuals (CSFII), 1994-96, Data Tables 9.4, 9.7, 10.4, 10.7. www.cspinet.org

(11.) Ludwig DS, Peterson KE, Gormaker SL Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. The Lancet, 357:505-508, Feb. 17, 2001.

(12.) 2000 National Household Survey of Drug Abuse, SAMHSA, www.samhsa.gov

(13.) Adolescent Health, United States 2000, CDC.

(14.) Making the Link, Alcohol Use and Girls' Health, Nov. 2001, CDC.

(15.) The Depressed Child, American Academy of Child and Adolescent Psychology; fact sheet. www.aacap.org

RELATED ARTICLE: is Your Teenager Depressed?

Depression in teens can be difficult to identify, says Adelaide Robb, MD, of the Children's National Medical Center in Washington, D.C. "They're not always as open about how they're feeling like younger children or adults, and often suffer in silence." Too often, they aren't diagnosed until something drastic happens, such as cutting themselves with a razor blade, eating problems, drugs or attempted suicide. If one or more of these signs of depression are persistent, depression may be present and your teen should see her health care professional for an evaluation.

* Frequent sadness, tearfulness, crying, hopelessness

* Decreased interest in activities

* Persistent boredom; low energy

* Social isolation, poor communication

* Low self-esteem and guilt

* Increased irritability, anger or hostility

* Difficulty with relationships

* Frequent complaints of physical illnesses such as headaches and stomachaches

* Frequent absences from school or poor performance in school

* Poor concentration

* A major change in eating and/or sleeping patterns

* Talk of or efforts to run away from home

* Thoughts or expressions of suicide or self destructive behavior (15)