A Grade 11 girl who is always tired: reading the diet behind the symptoms
A 16-year-old girl in Grade 11 comes to the school health clinic saying she feels tired all the time and cannot concentrate in class. She is 158 cm tall and weighs 47 kg. She says she has been skipping breakfast since January because she wants to lose weight; lunch is usually a bun and a sweetened fizzy drink from the canteen; dinner at home is rice with a small amount of vegetables. She drinks two cups of sweetened tea with no milk between meals. She has not had a period for four months, her nails are pale, and she feels cold even when others do not. Her mother says she is "just studying too hard". A four-day food record shows no eggs, fish, meat or pulses on any day.
1. Identify the nutrients most likely to be inadequate and match each one to the evidence in the scenario.
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Match each nutrient to a specific finding rather than listing deficiencies in general.
- Iron. Pale nails, constant tiredness and feeling cold all fit low haemoglobin, which carries oxygen and helps hold body heat. There is no meat, fish, egg or pulse in four days, and tea taken between meals contains tannins that bind plant iron and reduce absorption. Her periods have stopped, so menstrual blood loss is not the explanation - her intake is.
- Energy and starchy carbohydrate. Skipping breakfast creates a long overnight-plus-morning fast; a bun and a fizzy drink give a fast sugar rise followed by a dip, which explains mid-morning tiredness and poor concentration. At 47 kg and 1.58 m her BMI is about 18.8 - inside the normal range, but at its lower edge, and falling further.
- Protein. No pulses, egg, fish or meat at any meal means very little protein, so much of the weight she loses can be muscle rather than fat.
- Calcium and vitamin D. No milk or dairy at all, and tea is taken without milk.
- Vitamin C and fibre. Almost no fruit or vegetables, so plant iron is poorly absorbed and constipation is likely.
The overall picture is a diet low in iron, protein, calcium and total energy, and high in refined sugar.
2. Explain why her current weight-loss plan - skipping breakfast and drinking a sweetened fizzy drink at lunch - will not produce healthy weight control and may be making her feel worse.
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The plan attacks the wrong target and produces the wrong result.
- Skipping breakfast does not subtract a meal's worth of energy. A long fast leaves her hungry and low on glucose by mid-morning, which is why she cannot concentrate, and hunger then drives her to the quickest calories available - the fizzy drink and the bun.
- The fizzy drink is the problem, not the solution. One bottle can carry 8–10 teaspoons of sugar with no protein, iron or calcium, and adds dental risk.
- Low protein means muscle loss. With almost no protein and a large energy gap, the body breaks down muscle. Muscle is what burns energy, so her ability to control weight falls.
- Low iron reduces activity. Tiredness and breathlessness cut down the exercise that would help her most.
- Low energy availability affects hormones. With too little energy for her needs, the hypothalamus reduces the signals that drive the menstrual cycle, oestrogen falls, and periods stop. That is a warning about bone density too, not a convenient side effect.
The honest message is that she does need help with weight, but by eating more of the right foods and moving more, not by eating less of everything.
3. Write a one-day meal plan using foods available at home and in the school canteen that would meet her needs, and state what must happen about the missed periods.
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The plan must add iron, protein and calcium, spread energy across the day, and keep it affordable and familiar.
- Breakfast (before school): two string hoppers or two slices of bread with a boiled egg or dhal curry, plus a banana. Protein and iron at the first meal break the long fast.
- Mid-morning: a handful of peanuts or a piece of fruit from home, so she is not starving by lunch.
- Lunch (canteen): rice with dhal, green leaves or a mallum, and fish, egg or soya if available; water instead of the fizzy drink.
- Afternoon: a glass of milk or a curd, plus fruit - the vitamin C with a meal improves absorption of plant iron.
- Dinner: rice or roti with pulses and vegetables, and a fruit afterwards.
- Practical rules: keep tea at least an hour away from meals, use milk in tea, and swap the fizzy drink for water rather than simply removing it.
About the periods: four months without a period in a 16-year-old who is restricting food is a medical matter, not something to fix with diet advice alone. She needs to be seen by a doctor or the school medical officer, with her consent and preferably with a parent told, to rule out other causes and to assess bone health. Say this plainly and without alarm so she understands it is part of the same problem, not a separate punishment.