Ask a CHOC Doc: How can I safely gain weight?

Question: I am underweight, and don’t feel like eating sometimes. I am tired of not being able to gain weight. I tried talking to my doctor about it, but she didn’t give me a chance to explain; all she said was to eat more. When I was diagnosed with depression I wouldn’t eat as much and a part of that stayed with me I suppose. I don’t get hungry even when I want to eat. There is this supplement called Apetemin that helps people gain weight by making you feel hungry and slowing down your metabolism. Would you recommend it? -Anonymous


Identifying and maintaining a healthy weight is an important discussion, and a common one I have with teen patients. Here’s what I usually discuss with my patients:

  1. How to determine a healthy weight

To determine whether someone is medically underweight, doctors use a tool called Body Mass Index, or BMI. This is a calculation that uses height and weight to estimate how much body fat someone has. Doctors use it to determine how appropriate a someone’s weight is for a certain height and age. There are online tools to help you calculate your BMI at home.

BMI is the most common measure about what weight is appropriate for someone’s height—but there are exceptions to this guideline. BMI is not always the best measurement for everyone. To determine a healthy weight for you, have a conservation with your doctor. Work with them to identify a healthy weight.

  1. How to know when skipping meals is a cause for concern

It’s ok if you skip a meal every now and then because you’re stressed or sick. That’s normal. Some days our bodies are hungrier than others, and that’s ok. If skipping meals becomes a regular thing, or if you’re unable to complete meals on a regular basis, talk to your doctor. If you’re also experiencing stomach problems like vomiting or diarrhea, see your doctor.

  1. How appetite plays into mental health

If this feeling of not being able to eat accompanies sadness, worry or sadness, speak to your doctor. You can also speak to a trusted adult like a school counselor who can help you find a psychologist or other mental health professional. Depression and anxiety are common problems that can cause changes in appetite and eating. These are chronic problems that can have times where they’re pretty severe, and other times where symptoms are not present, but they can still affect your appetite or mood. It’s important to have an ongoing conversation with your physician about your mental health. They can help you find the resources you need, including a psychologist.

  1. Be cautious with supplements

If you are underweight and having trouble eating, your doctor may recommend seeing a nutritionist for recommendations on food and supplements. Always discuss supplements with a provider, as they are not well regulated and need to be taken under the supervision of a doctor or nutritionist.

Appetite stimulants may be prescribed, but can come with adverse effects, including abnormal changes to the immune system, nausea, stomach problems and fatigue.


-Dr. Terez Yonan, adolescent medicine specialist at CHOC Children’s

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The female athlete triad: What you need to know

By Dr. Amanda Schafenacker, pediatric resident at CHOC Children’s

The female athlete triad, commonly called “the triad,” is a significant phenomenon being seen more and more in middle school and high school female athletes. The triad consists of three health concerns: disordered eating, low bone density (osteoporosis), and loss of periods (amenorrhea). While we always encourage children and adolescents to exercise, the triad can be seen in females involved in sports.

The triad occurs when the calories a female athlete is consuming doesn’t compensate for how much exercise girls she’s doing. To make it simpler, the amount the teen is eating is not enough to support the energy needs for daily life plus exercise. This has adverse effects on reproductive, bone and cardiovascular health.

The full triad occurs in 1 percent of all high school girls and 16 percent of all female athletes—but many adolescents may only exhibit one or two of the components, which can still have adverse effects on health. This also means a higher percentage are at risk for the full triad over time if their nutritional habits do not improve.

Disordered Eating

While some athletes may be obsessively counting calories, or practicing other unhealthy weight loss techniques such as unnecessarily restricting food items or entire groups, vomiting, diuretic or laxative use, some athletes may simply be unaware they are not consuming enough calories to support their active lifestyles. When the calorie intake does not equal the calories consumed by the body, the body starts to break itself down, which can lead to problems in different organ systems.

Potential triggers for disordered eating includes prolonged periods of dieting; weight fluctuations; coaching changes; injury; and casual comments about weight from coaches, parents, or friends. Many athletes falsely believe that losing weight will improve their athletic ability and that thinner means faster or more agile, but this is not true. This is dangerous. These ideas are common among dancers, gymnasts and swimmers, but can also be seen among runners, soccer players, and in wrestlers or boxers as athletes fluctuate through periods of “cutting weight” and gaining weight.

Loss of muscle mass happens quickly after you begin restricting food intake. This leads to decreased speed, decreased agility, decreased coordination, and increased risk of injury of muscles or bones.  Parents should be vigilant if they notice significant weight loss, their children restricting food, or purging habits (like inducing vomiting or laxative use), and bring their child to the doctor.

It is important for any athlete to remember, if a coach or family member feels it is necessary for the teen to gain or lose weight, to do so safely with the help of a doctor.

If you or your teen have questions about how much food the body needs to keep up with natural metabolism and athletic activities, talk to your doctor or a pediatric nutritionist to get more information.

Bone Disorders

As teens continue to grow, this is a critical time for bone mass creation. Without enough energy for daily function and exercise, bone growth and strength (also known as bone mineralization) can diminish. Decreased bone mineralization leads to muscle and ligament injuries, or even as bone fractures. Bone growth during the teen years is critical to prevent osteoporosis (weak bones) in adulthood. Peak bone mass usually occurs between ages 20 and 30, but up to 90 percent of bone mass is obtained by the time teens finish high school.


After the first menstrual period, adolescents’ periods should become regular within one to two years. Going without a period for more than three months is called amenorrhea. There are many causes of amenorrhea in teens, but considering low or inadequate caloric intake is necessary in all female athletes. Without enough calories to support the hormones that cause periods, female athletes may stop having their periods or start having irregular periods. Studies have shown that athletes with period irregularities can be three times as likely to have bone injuries and other muscle or ligament injuries than those athletes who maintain normal periods. The usual treatment for regulating periods is increasing nutritional intake (eating more) or decreasing vigorous activity, or a combination of both.

What should I do if I suspect this is me?

Talk with your doctor! At any sports physical, your doctor should be evaluating you for all of the above. At your visit, you can expect to have your vital signs taken (things like blood pressure, heart rate, weight and height) and have a thorough physical exam performed. Your doctor may ask you to have some blood tests done, especially if you are not having regular periods. In extreme cases, your doctor may have a bone scan done to see how your bones are growing.

What happens if I’m diagnosed with female athlete triad?

The ultimate goals are to restore normal periods and weight safely. Overall, you need to start increasing the amount of healthy calories you consume to get the energy your body needs on a daily basis. Treatment plans often include decreasing exercise while increasing calories in meals. To restore bone density and growth, your doctor may encourage vitamin supplements including vitamin D and calcium. You may be referred to a multi-disciplinary team where a doctor, a dietitian, and a mental health professional can help set appropriate nutrition and exercise goals.

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Heavy Periods (Dysmenorrhea): Should You Be Worried?

By Dr. Arpine Davtyan, pediatric resident at CHOC Children’s

Heavy periods, also known as dysmenorrhea, can be painful, and is one of the most common medical problems teen girls face. More than 60 percent of teenage girls report painful periods. Periods usually become painful within the first few years after you begin menstruating, and they become less common with age. Dysmenorrhea is split into two major categories.

  • Primary dysmenorrhea occurs when there is pain with menses, typically crampy and located in the lower abdomen or lower back, without the presence of any diseases that could possibly be causing the pain. The pain typically begins as soon as menstrual bleeding occurs, or right before the start of bleeding and lasts one to three days.
  • Secondary dysmenorrhea is when you have the same symptoms listed above, but along with a diagnosis like endometriosis which could be causing the pain. Secondary dysmenorrhea is more common in older women.

During menstruation, the lining of the uterus produces hormones called prostaglandins, which cause the muscle cells that make up the uterus to contract. The contractions lead to painful cramps that characterizes dysmenorrhea. These prostaglandins are also responsible for nausea and diarrhea during menses.

How is dysmenorrhea diagnosed?

Dysmenorrhea is usually diagnosed by your doctor with a history and physical examination. Additional testing, such as an ultrasound of the pelvis, may be performed to look for conditions like endometriosis or fibroids which could be causing the pain. Laboratory testing or imaging is usually not required.

How is dysmenorrhea treated?

First, let’s talk about non-pharmacologic treatments―treatments that do not require medication. Herbal treatments, dietary and vitamin supplements have been studied on a small scale, but we do not have enough information about safety or effectiveness. Therefore, we don’t recommend any supplements for the treatment of dysmenorrhea. There have also been studies showing that yoga or acupuncture may help with dysmenorrhea and while this association needs to be further studied, these activities are not harmful and may be effective.

Studies have shown that exercise can lead to a decrease in menstrual pain. Since exercise also has many other benefits (decreased anxiety, depression, stress, diabetes, cancer, cardiovascular disease, in addition to improved cognitive functioning and more), we recommend regular exercise for those with dysmenorrhea. A heating pad, hot water bottle or a heating patch can also help decrease menstrual pain and can be used as often as necessary. Ensure that the temperature of the heating method you use is not higher than 104 degrees Fahrenheit to avoid burns.

There are a variety of medical treatments available for heavy periods or dysmenorrhea. Over-the-counter medications such as ibuprofen (Advil or Motrin) are the most commonly-used medication to treat dysmenorrhea. These medications provide pain relief in patients with heavy periods or dysmenorrhea by decreasing production of prostaglandins, the hormone which causes the cramps in the abdominal or lower back pain These non-steroidal anti-inflammatory drugs (NSAIDs) work best when taken right before or as soon as bleeding begins, and then taken regularly for two to three days. Talk to your doctor to be sure it is safe for you to use this readily available medication.

Hormonal birth control― including the pill, patch, vaginal ring, injection, implant, IUD― have been shown to be effective in controlling menstrual pain. These treatments thin the lining of the uterus, which means less of the prostaglandin hormone is produced, leading to less contraction of the muscle cells of the uterus that causes cramps. Patients taking hormonal birth control in the form of the pill, patch or ring normally take them in a way that allows them to have monthly periods. Patients with severe dysmenorrhea can choose to take these treatments continuously and NOT have monthly bleeding; talk to your doctor to see how to use birth control for this added benefit. These treatments are usually effective for most women. If these treatments fail, then a detailed discussion with your doctor is necessary to determine what further testing or alternative medications may be necessary.

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My Child is Almost a Teenager. What Should I Expect?

By Dr. Ronald Hirokawa, pediatric resident at CHOC Children’s  

It’s no secret that adolescence is one of the most difficult phases in someone’s life. As a parent, you might feel just as confused as your teenager when trying to navigate this stage. You want to support your child and help them navigate what can be a confusing time. To do that, you need information you can rely on. The problem is, most parents are experiencing information overload and don’t know what source to trust.

At CHOC Children’s, we believe parents should feel like they’re the experts in their child’s health. We know it can be stressful to navigate puberty with your children. Every year, we care for 250,000 kids and teens in Orange County and beyond. We’re committed to providing quality education around the topics parents ask us about the most.

Major physical changes can cause major stress for teens. Unlike the hormonal and psychological changes that are mostly unseen, these physical changes are visible every morning when they look in the mirror.

This parents’ guide to puberty will help you prepare for changes you can expect in your child, but also for answering their questions.

Physical Changes

Your teen will likely experience many physical changes during puberty. Here are a few to expect:

Growth spurt: About 20 percent of our height is obtained during puberty. Most girls start their growth spurt between ages 10 to 14, or about a year after puberty begins. Males have their growth spurt on average two years after the start of puberty. Males also tend to grow faster.

Bone growth: As teens get taller, their bones growth accelerates as well. Bones first grow in length, then width, and then density. Due to this growth pattern, there is a high risk of fracture as teens’ bones get longer before they get stronger.

Changes in body shape: While both males and females see increases in their body mass index (BMI), girls see more of an increase in body fat. Boys, however, tend to have increased levels of lean body mass. This can cause high levels of stress in adolescent females, especially in a culture that promotes thinness. Conversely, puberty leads to fat distribution in the hips and butt, which can lead to unwanted attention. Parents may worry that this may be a sign of future obesity, but they should be reassured that the body redistributes the fat to other parts of the body as it progresses to adulthood.

Changes in Sexual Characteristics


Breast development: The first phase of puberty in females is the development of breast buds, which appear as coin-sized lumps under the nipples. This phase normally occurs around age 9 or 10. Studies have shown that African American girls usually enter puberty a bit earlier, around 8 to 9 years of age. Girls should be evaluated by their pediatrician for early puberty if breast development starts earlier than age 8 for Caucasians and 7 for African Americans.

  • Breasts may be uneven during early development but should even out within about a year. Consider options like padding one side of your teen’s bra if uneven breast size is causing stress.
  • Training bras are not critical at this period and can actually cause discomfort to sensitive early breast tissue. Consider alternatives such as soft, light, gentle undergarments like an undershirt or sports bra.

Pubic hair: In the second phase of puberty, your teen will develop pubic hair. Ten to 15 percent of girls will see public hair before they develop breast buds. Initially, the hair starts off soft, straight, sparse and in close proximity to the vagina, but will begin to spread to the lower abdomen and inner thigh areas and take on a triangular pattern. The hair will also begin to appear darker, curlier and coarser.

Menstruation: Most girls get their first period around age 12 or 13. African American pre-teens tend to start menstruating one year earlier. Parents can expect their daughters to start menstruating two to three years after breast bud development. Cycles will often be irregular, especially between the first and second cycles. On average the first cycle for most girls lasts 34 to 40 days. A cycle length is measured from the start of one period to the day before the next flow. About two years after the first period, cycles should regulate, occurring once every 21-45 days, lasting no more than seven days.  Most girls need an average of four to five regular pads on the day their flow is heaviest.

  • Consider discussing menstruation when teen starts breast development, so they know what to expect. Helpful strategies include using visual aids such as books and pamphlets while trying to describe and explain the female reproductive system. Your daughter’s pediatrician or an adolescent medicine specialist can help provide education.
  • It is vital that female teenagers are prepared and educated on what to expect. Make sure that your teenage has pads available at school in case of emergency. Deciding between tampons and pads should be left up to the comfort and preference of your daughter. Although there is no way to pinpoint exactly when your daughter will get her first period, it often occurs at around the same time it did for her mother or older sisters. If menarche has not occurred by age 16, seek a medical evaluation by your primary care physician.
  • See your doctor if periods are infrequent, too frequent, flow is extremely heavy, or periods are painful.


Testicular and scrotal enlargement: At around 11 to 12 years of age, males experience a near doubling in testicular volume in this first phase of puberty. This occurs on average six months prior to increase in penile size. The scrotum also starts to darken, enlarge, hang down from the body, and develop tiny bumps or hair follicles. Males should be evaluated by their pediatrician if puberty starts before age 9 or shows no signs of puberty by age 14.

Pubic hair development: This usually develops at age 12 or 13. Hair starts off light, sparse, soft and mostly located at the base of the penis. The hair will start to become darker, curlier and coarser. It will also start to spread to the rest of the pubic region, toward the thigh, and towards the belly button in a diamond-shaped pattern. Around two years later, they will begin to develop hair on other parts of the body such as their face, legs, arms, underarms and chest.

Penis growth: Males may achieve adult-sized genitalia between the ages of 13 and 18. Penile size increases first in length and then width. Size can vary greatly from male to male. Many male teens may become distressed with penile size as they compare themselves to other males. Remind your teen that function does not depend on size.

Adolescent Cognitive Development:

During puberty, your teen will also undergo significant cognitive changes. Before puberty, your teen still thinks in concrete terms: Things are black and white, right or wrong. They often only think about what is going on in the present moment and only consider the immediate consequences of their actions, rather than thinking long term.

During the mid-teen years there may actually be a drop in the level of maturity and judgment for certain teens. This is not always a bad thing, as teens will experiment in their own way to learn about the world. They typically put this information to good use, learning about their mistakes. However, risk-taking behavior may lead to violence or experimenting with alcohol or drugs in some cases.

By late adolescence, teens begin to think more abstractly and in shades of grey. They are also now able to analyze situations logically, reason effectively, solve complex problems, and achieve increased empathy, allowing them to get a sense of what others are thinking.

This higher level of cognition allows them to start planning for their future and think about the more long-term consequences of their actions. Teens still have very little experience with this level of decision making and may need assistance directing these newly gained cognitive skills.

Learn more about understanding the teen brain.

How can I help my teen during this phase?

Teens often make snap decisions, leading to risky behaviors. Expand their range of options and teach them to consider multiple choices and to weigh the potential risks and benefits of each decision. During this time, it’s important to help your teen understand that emotions, good or bad, may affect their ability to make rational decisions.

Teens are often influenced by social pressures from other teens, which can lead them to participate in risky behaviors. Instead of imposing your opinions on your teen, provide them with objective information about these behaviors.

Concerns about popularity and acceptance are most intense during the early teen years and may lead teens to participate in risky behaviors. Parents can help teens resist these pressures and find alternative groups. Explain your family’s set of values, like respecting yourself and others, the importance of trust, etc.

Although during the teen years there is often less time being spent with family, family closeness is still an extremely important component of adolescent development and has been associated with a lower incidence of smoking, alcohol and drug usage, and suicide attempts.

How to Talk to My Teenager:

Simply asking questions and listening without judgment can be majorly influential. Ask non-threatening questions that help them define their identities, such as:

  • Who do you admire and why?
  • What are your hopes for the future?
  • What are your strengths?

To create a nonjudgmental environment, listen more than you speak. Ask open-ended questions to encourage them to think through their answers as opposed to just saying yes or no. Match their mood to help your teen feel like you understand where they are coming from.

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Protein Powders and Teens: Are They Safe? Are They Necessary?

By Dr. Jacqueline Winkelmann, pediatric hospitalist at CHOC Children’s


As a pediatrician and sports nutrition expert, I repeatedly get asked by coaches, parents, and young athletes: “What are the best protein supplements on the market? Are they safe? To me, the bigger question is, “Are protein supplements even necessary for young athletes?”

At one time, it was believed that muscle-building exercises in athletes greatly increased dietary protein needs. This idea led to a multibillion-dollar industry selling high-protein meals, bars and drinks marketed to athletes. Here are the most common questions I get on protein powders and young athletes—and what I tell parents when they ask.

How much protein do young athletes need?

The current recommendation for protein for young athletes is approximately 1.0-1.4 grams per kilogram per day, which means they need slightly more protein than their non-athlete peers This extra protein in their diet helps to sustain growth and development, muscle building and repair, as well as fueling intense exercise. This means, a 150-lb athlete should consume 80 grams of protein, or 20 extra grams a day. Recent studies have shown young athletes consume 2-3 times the recommended amount of protein per day in their diet alone.

What are the best sources of dietary protein?

The richest sources of protein are lean meats such as chicken, turkey, lean beef, fish, eggs, tofu, dairy products (milk, cheese, yogurt), beans, lentils and nuts.

Will eating extra protein make my young athlete stronger?

While it may seem sensible that “more is better” when it comes to protein, that’s simply not true. Studies show that consuming extra protein will produce no further gain in strength, muscle mass or size. The reason for this is simple; young athletes need anabolic hormones (i.e. testosterone) and physical training in order to stimulate protein synthesis and in turn increase muscle mass. The amount of protein they eat is irrelevant without the complete regimen.

What are some of the side effects or consequences of consuming too much protein?

High protein, low carb diets are never recommended for young athletes. Too much protein will cause problems. Since our bodies can’t store extra protein to use later, we will have to spend a significant amount of energy processing it, using up energy and water, two important resources for athletes. Eventually, extra protein will be converted into fat. Too much protein can cause nausea, loss of appetite, diarrhea and can even stress the liver and kidneys.

Is the timing of protein intake important?

YES! This we can pay attention to; small amounts of protein throughout the day is the most efficient and effective way to consume protein. Pay special attention to snacks before and after exercise. Athletes recover faster when they eat some protein within 30 minutes of exercise. Aim for 20-25 grams of protein as part of the pre- and post-recovery snacks. For example, a 4-ounce serving of chicken, fish or beef provides between 25-30 grams of protein, an egg provides 6 grams, and a cup of milk 8 grams of protein.

Could protein supplements/powders benefit my young athlete?

There has been great hype created around protein powders and their importance for athletes. They are for the most part unnecessary for young athletes. W know young athletes have a slightly increased protein requirement, they should be able to easily obtain their protein from food rather than supplements. Protein powders are not currently regulated by the FDA. This means they may contain artificial sweeteners, heavy metals and other chemicals that young athletes are just better off without. Plus, they’re expensive!

Who might benefit from protein supplements?

Athletes who are vegetarian or vegan, those who have certain medical conditions, or those who are underweight might benefit from protein supplements after establishing that he or she does not consume enough protein in his/her diet. Protein intake should be supervised by a dietitian, nutritionist or health professional.

What should parents consider if purchasing protein powders?

Food is the best source of protein, but, if your athlete needs a protein supplement, do your research! Be aware that price does not correlate with purity. Look for those supplements with high ratings from the Clean Label Project or the National Sanitation Foundation (NSF).

What are some strategies for safe weight gain and increasing muscle mass especially for adolescent athletes?

There are three key components to muscle building: calories, resistance training and rest. The American Academy of Pediatrics Committee on Sports Medicine and Fitness recommends exercises focusing on core strength, balance and agility for pre-adolescent athletes, and only after puberty should they consider adding muscle bulk.

How can I help my teen increase their caloric intake in a healthy way?

Increase calorie intake by 300-500 calories per day with a little extra protein. To increase calories:

  • do not skip breakfast
  • aim to eat 5-9 times per day
  • increase portion size
  • add nuts, extra sandwich or bowl of cereal before bed

What should my teen know about resistance training?

Muscle growth is accelerated with the onset of puberty, around age 13-18 years old. Resistance training is key when the goal is to increase muscle mass, size and strength. This can in fact increase muscle weight by up to 15 percent per year during these years. A general strengthening program should have an adequate warm up and cool down and address all major muscle groups.  It’s important to train with focus and intensity, not just go through the motions. For increase in muscle size: do multiple sets of 8-15 repetitions/set. For increase in power/strength: lift heavier weights and do multiple sets of 4-6 reps/set. Training should always be done under adult supervision by a certified professional.

How important are rest days?

Rest is an essential part of maintaining a healthy lifestyle. Strength training for a particular body part should be done on non-consecutive days. Just as important, the body needs to rest in order to rebuild muscle fibers and increase muscle mass. Adolescents should get between 8-9 hours of sleep per night.

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