Nutrition During The Life Cycle

Nutrition During the Life
Cycle
Life Cycle: The various stages of

life from prenatal (before birth) to
death.
Department of Nutrition and food hygiene
Lu Quanjun
Tel:0371-67781923
Email:lqjnutr@zzu.edu.cn
Objectives
Understand major changes in
physiology, development, behavior
and psychosocial factors
throughout life
Describe how these factors

influence/are influenced by nutrition
Developmen
Food tal Stage
Availability
Behavioral
Patterns
Food Safety
Nutrition &
Health Income
Cognitive
Status
Abilities/Disabiliti
es
Physical
Abilities/Disabiliti
Activity Patterns
es
Expectations:
Come prepared
Read, come to class, read
Ask questions
Section 1
Nutrition During Pregnancy and
lactation
Pregnancy is a time
of rapid growth of
the fetus. A woman
may not realize she
is pregnant.
A woman of child-
bearing age needs to
develop good eating
habits and continue
throughout her life.
1.Nutrition During Pregnancy
1.1Physiology of pregnancy
 Stages of human fetal growth
 Blastogenic stage: first 2 weeks
 Cells differentiate into fetus, placenta
 Embryonic stage: weeks 3-8
 Development
of organ systems
 Fetal stage:
week 9-delivery
 Growth
Pregnancy
Physiology of
pregnancy
 Maternal changes
 Growth of adipose,
breast, uterine
tissues
 Increase blood volume
 Slower GI motility
Organ systems
Cardiovascular system
Pulmonary system
Genital tract
Urinary system
Endocrine system
Gastrointestinal Tract
Skin
Total body water
Increases 6-8 L
Increases by 40 %
Normal body water
 2/3 intracellular
 1/3 extracellular
 ¾ interstitial
 ¼ intravasular
2/3 increase is extravascular
Physiologic anemia of
pregnancy
Physiologic intravascular change
Plasma volume increases 50-70 %
 Beginning by the 6th wk
RBC mass increases 20-35 %
 Beginning by the 12th wk
Disproportionate increase in plasma
volume over RBC volume----Hemodilution
Despite erythrocyte production there is a
physiologic fall in the hemoglobin and
hematocrit readings
anemia & not given
supplementation
concentratio Non 1st 2nd 3rd deliv
n preg Tri Tri Tri
HB 13.0 12.2 10.9 11.0 12.4
Serum 90.0 106.5 75.3 56.0 57.1

iron
Serum 63.0 97.4 22.2 14.7 27.6
Ferritin
Wide standard deviation Williams 21ed
Iron deficiency anemia
With erythropoiesis of pregnancy, iron
requirements increase.
Because large amounts of iron may not be
available from body stores and may not be in the
diet
Supplementation is recommended to prevent iron
deficiency anemia
At term, Hemoglobin less than 10.0 is usually due
to iron deficiency anemia rather than the
hemodilution of pregnancy
Normal Iron Requirements
Total body iron content average in normal
adult females is 2gm
Iron requirement for normal pregnancy is
1 gm
 200 mg is excreted
 300 mg is transferred to fetus
 500 mg is need for mom
 Total volume of RBC inc is 450 ml
 1 ml of RBCs contains 1.1 mg of iron
 450 ml X 1.1 mg/ml = 500 mg
Daily average is 6-7 mg/day
Small intervals between pregnancies are
most concerning
Cardiovascular system
Total Body water
Cardiac Output
Cardiac output (CO=HR X
SV)
Begins to increase by the 5th wk
Rise of 40 % by 20-24 wks
Initial increase is a function of
 The increase in heart rate
 Reduced systemic vascular resistance
By 10- 20 wks the increase in CO is reflected
mainly by the increase in SV
 The notable increase in plasma volume or preload
contributes to the increase SV
As pregnancy advances to term, the HR
continues to increase but the SV falls to close
to normal levels, this accounts for the fall in CO
to near non-pregnant levels at term
Interpretation of tests
during pregnancy
CXR
 Elevation of diaphragm
 Heart to be displaced to the left and upward
 Increase in the cardiac silhouette
 benign pericardial effusion
Echocardiogram
 Increased left ventricular wall mass
 Increased end diastolic dimensions
 Increase in EDV and therefore inc in SV
Electrocardiogram
 Slight left axis deviation
Respiratory system
Mechanical
 diaphragm
Consumption
 Increase in needed oxygen
Stimulation
 Progesterone stimulation
Respiratory
Mechanical
 Diaphragm rises 4 cm
 Less negative intrathoracic pressure
 Dec FRC-Functional Residual Capacity
 volume after passive expiration
 Dec ERV-Expiratory Reserve Volume
 max volume expired after expiration
 Dec RV-Residual Volume
 volume after max expiration
 No impairments in diaphragmatic or
thoracic muscle motion
 Lung compliance remains unaffected
Respiratory
Consumption
 O2 consumption Increases 15-20 %
 50 % of this increase is required by the uterus
 Despite increase in oxygen requirements, with
the increase in Cardiac Output and increase in
alveolar ventilation oxygen consumption exceeds
the requirements.
 Therefore, arteriovenous oxygen difference falls
and arterial PCO2 falls.
Respiratory
Stimulation
 Progesterone is known to directly
stimulate ventilation
 Progesterone increases the sensitivity
of the respiratory centers to CO2
 Also, it is thought to reduce total
pulmonary resistance
Respiratory
Minute ventilation = RR X Tidal volume
Tidal Volume-increases
 Volume of air Inspired and expired with each
breath
Minute ventilation-increases
 Volume inspired or expired in 1 min
RR- remains unchanged
Vital capacity-remains unchanged
 Max volume that can be forcibly inspired after
max expiration
Physiologic changes
Dyspnea-increase in desire to breathe
 70 % of pregnant women experience this
 Occurs during 1st trimester without mechanical
factors
 No change on PFTs
 The lower PCO2 then paradoxically causes
dyspnea
 The marked change or marked decline in PCO2
results in the sensation of dyspnea
Genital Tract
Increased vascularity and hyperemia
 Vagina
 Perineum
 Vulva
Increased secretions
Characteristic violet color of the vagina
 Chadwick’s sign
Increased length to the vaginal wall
Hypertrophy of the papillae of the vaginal
mucosa
Genital Tract
Uterine hypertrophy of the myocytes
Hypertrophy can cause venous
compression
 Can result in fall in venous return
 Furthermore a fall in CO
 Physiologic compensation
 Rise in peripheral resistance to minimize fall in
blood pressure
Genital Tract
Without Physiologic compensation
Supine hypotensive syndrome can
occur with a gravid uterus
 Symptoms-Nausea, dizziness, syncope
Can be relieved with position
changes
Gravid uterus has limited
autoregulation
Uterine blood flow is Increased 100 ml/min
to 1200 ml/min
Because uterine vessels are maximally
dilated little autoregulation can occur to
improve flow during perfusion pressure
changes
When maternal Cardiac output declines,
blood flow is shifted away from the
uteroplacental circulation to the maternal
brain, kidney and heart.
Urinary System-Dilation
Calyces, renal pelves, and ureters
undergo marked dilatation
More prominent on the right
Partial obstruction of the ureters
can occur at the pelvic brim
Progesterone produces smooth
muscle relaxation which is thought
to cause the relaxation noted
Urinary System-inc GFR
GFR and renal plasma flow increases 40 %
by mid-gestation
Plateaus, then remains unchanged until
term
Elevated GFR is reflected in the lower
serum levels of creatinine and blood urea
nitrogen
NL GFR 120-160 ml/min
Urinary System-Proteinuria
Normally not evident
Average is 115 mg/day
260 mg/day is in 95 percent
confidence limit
Therefore, our 300 mg screen
would exceed most normal
variations
Endocrine
Normal pregnancy physiology shows
 “lower lows and higher highs”
Postprandial hyperglycemia
 To ensure sustained glucose levels for fetus
Accelerated starvation
 Early switch from glucose to lipids for fuels
Insulin resistance promotes hyperglycemia
 Resistance-Reduced peripheral uptake of glucose for
a given dose of insulin
Mild fasting hypoglycemia occurs with elevated
FFA, triglycerides,and cholesterol
Insulin resistance
Anti-insulin environment is aided by:
placental lactogen
 Like growth hormone
 Increases lipolysis and FFA
 Increases tissue resistance to insulin
Increased unbound cortisol
Estrogen and Progesterone may also
exert some anti-insulin effects
Thyroid
Estrogen stimulates Increase in
TBG(thyroxine-binding globulin )
 Total T3 and T4 are increased
 However the active hormones remains
unchanged
hCG(Human chorionic gonadotropin)
stimulates thyroid
 TSH is reduced
Iodine deficient state
 Due to Increased renal clearance
To rule out pathologic changes
 Early in pregnancy TSH can be used
 Later free T4 is needed
Figure 1. Thyroid-stimulating hormone (TSH) and human chorionic
gonadotropin (hCG) during gestation. Note the reciprocal
relationship between TSH and hCG.
(Adapted from Glinoer D 1997 The regulation of thyroid function
in pregnancy: pathways of endocrine adaptation from physiology
to pathology. Endocrine Reviews 18:404-433)
Figure 2. Thyroxine (T4) Concentrations During Gestation
(Adapted from Burrow GN, Fisher D, Larsen PR: Maternal
and fetal thyroid function. N Engl Med 331:1072, 1994.
Copyright?994 Massachusetts Medical Society. All rights
reserved.)
Gastrointestinal Tract
Displacement of the stomach and intestines
Appendix can be displaced to reach the right flank
Gastric emptying and intestinal transit times are
delayed secondary to hormonal and mechanical
factors
Pyrosis is common due to the reflux of secretions
Vascular swelling of the gums
Hemorrhoids due to elevated pressure in veins
Liver
Liver morphology unchanged
Lab Tests similar to liver disease
 Alkaline phosphatase doubles
 AST, ALT, GGT and bilirubin are
slightly lower
 Decreased plasma albumin
Gallbladder
Impaired contraction
High residual volumes
Promotion of stasis
Stasis associated with increased
cholesterol saturation of pregnancy,
supports predisposition of stones
Intrahepatic cholestasis
Retained bile salts-pruritus gravidarum
Skin changes
Chloasma or melasma gravidarum
Striae
Linea nigra
Melasma
Melasma
Melasma
Also known as the mask of pregnancy
More common in dark skin people
More pronounced in the summer
Fades a few months after delivery
Repeated pregnancy can intensify
Can occur in normal non-pregnant
women with harmless hormonal
imbalances or women on OCPs or depo
Striae
Striae
Reddish slightly depressed
Breasts, thighs, and abdomen
In future pregnancies they appear
as glistening, silver lines
Linea nigra
Hyperpigmentation
Melasma and linea nigra
Estrogen and progesterone
Some melanocyte stimulating
effect
Weight Gain
Recommendations
Prepregnancy BMI Weight Gain

(kg/m2)
Low (<19.8) 28-40 pounds
Normal (19.8-26) 25-35 pounds
High (>26-29) 15-25 pounds
Obese (>29) At least 15 pounds
Teens should strive for weight gain at upper end of ranges to

support own and baby’s needs for growth and development.
Institute of Medicine of the National Academy of Sciences, 1990
Effects of Poor Nutrition
During Pregnancy
Low birth weight (less than 5 1/3 lbs.)
Mental Retardation
Blindness
Fetal Alcohol Syndrome (FAS): Birth
defects from mother consuming alcohol
during pregnancy
Spinal Bifida from lack of folic acid (folate)
Nutrition for Pregnancy
Increased energy needs (+200 Kcals)

Increased protein needs (+15-25 g)
This amount is usually met by average
American diet.
Increased need for many vitamins and
minerals
Focus on nutrient-dense foods
Pregnancy
Energy and nutrition during
pregnancy
 Micronutrients
 Increase need for most vitamins and minerals
 Highest increase for iron and folate
Food choices for pregnant women

 Pyramid-style diet
 Supplements of iron and folate
Substance use
 Risk for birth defects,
low birth weight, preterm delivery
Evidence of Nutritional
Intervention Effectiveness
Maternal malnutrition
Folate
Iron
Iodine
Vitamin A
Zinc
Calcium
Maternal Malnutrition and
Pregnancy Outcome
Severe nutritional deprivation (Netherlands 1944–45)
 Birth weight significantly influenced by starvation
 Perinatal mortality rate not affected
 No increase incidence of malformation
 In healthy women, state of near starvation is needed to
affect pregnancy outcome

Severe nutritional deprivation (Netherlands 1944–46)
 Periconception: Decreased fertility, increased neural
tube defect
 1st trimester: Increased stillbirths, preterm births,
early newborn deaths

 3rd trimester: Low birth weight, small for gestational
age, preterm birth
Cunningham et al 1997; Susser and Stein 1994.

Maternal Malnutrition and
Pregnancy Outcome
(continued)
Dietary restriction trials in pregnant women
 High weight for height or high weight gain
 Inconclusive results to demonstrate or exclude effect
on fetal growth or any significant effect on other

outcomes
Mixed result with nutritional supplementation trials
 High protein: No evidence of benefit on fetal growth
 Balanced protein and energy: minimal increase in
average birth weight (~30 g) and small decrease in

incidence of small for gestational age newborns
 Women manifesting nutritional deficits can benefit
from a balanced energy/protein supplementation
Enkin et al 2000; de Onis, Villar and Gülmezoglu 1998.

Energy Requirements for a
Successful Pregnancy
Increase in maternal tissue (breast

tissue, uterine muscles, placenta)
Increase in fetal tissues
Metabolic “cost” of pregnancy = tissue

accrued + metabolic needs of new
tissue = ∼ 80,000 kcal
Physiologic Changes of
Pregnancy
Maternal anabolic phase: 0-20 weeks

 “building up” of mother’s body to supply increased needs of
fetus later
 10% of fetal growth occurs in this phase
Maternal catabolic phase:20 weeks – Birth
 Delivering stored energy & nutrients to growing fetus
 90% of fetal growth occurs in this phase
Energy Requirements
Energy utilization during pregnancy:
 Maternal gain breast tissue, uterine muscles and placenta

(27,000 kcal)
 Fetal tissues (27,000 kcal)
 Increased work of maternal heart (27,000 kcal)
Result: BMR ↑ 60% 2nd and 3rd trimesters (catabolic

phase)
How is this achieved?
Adaptation for Pregnancy
3 possible adaptive responses:
 Increase in intake
 Decrease in expenditure
 Metabolic adaptations to increase availability of
energy and nutrients
Usually all 3, but varies from woman to

woman
Metabolic Alterations
Hormonal Changes
HCG (human chorionic gonadotrophin)

secreted within days of implantation –
maintains corpus luteum
HPL (human placental lactogen) - ?fetal/
placental growth factor
Estrogens – influences reproductive
organs, ↑binding hormones, influence
macronutrient metabolism
Progesterone – relaxes smooth muscle
(GI, urinary tracts)
Protein Metabolism
 Gradual adaptation of protein metabolism to
increase nitrogen retention in last 10 weeks (4
x non-pregnant)
 ↓ urea synthesis & excretion
 ↑ excretion of other N wastes (due to ↑ GFR)
Needs must be met by maternal intake or

greater change in adaptations needed - limited
Fat Metabolism
Fat storage (30,000 kcal) to 20 weeks
Early: Estrogen, progesterone and insulin favor fat
deposition, inhibit lipolysis
 ↑TG, FA, Cholesterol, Lipoproteins, Phospholipids
 Cholesterol used by placenta for steroid synthesis, FA for
oxidation & membrane synthesis
Late: HCS (human chorionic somatomammotropin)
favors lipolysis, fat mobilization for mother, aa &
glucose for fetus
Table 4-9, p.81
CHO Metabolism
Changes directed toward maintaining availability

of glucose for fetus
Early pregnancy (12-14 weeks) – enhanced early

insulin secretion but insulin sensitivity, glucose
production unchanged→favors fat storage
CHO Metabolism - 2
Through pregnancy (hormonally mediated):
 ↑ insulin secretion
 ↓ insulin sensitivity
 ↑ hepatic glucose production
By 3rd trimester:
 Basal, post-prandial insulin 2 x non-pregnant
 Insulin response 3-3.5 x that in non-pregnant state
 Insulin action 50-70% less than non-pregnant state
Fig. 4-4, p.80
CHO Metabolism - 3
End result: increased glucose availability
 ↑ glucose production
 ↑ insulin secretion, but decreased sensitivity of maternal
peripheral tissues, less glucose uptake by tissues
 Hormonally mediated preferential use of non-glucose
fuels (lipolysis) by maternal peripheral tissues
Fuel Utilization: ?A Paradox
RQ as measurement of fuel utilization:
CO2 production/O2 consumption
0.7------- ↑ --------.82-------- ↑ --------->1.0----->1.0+

Fat Fasting protein Fed CHO Overfed
(0.75-.85) (0.85-.95)
 What would the RQ of a pregnant woman be?

Fuel Utilization
RQ in late pregnancy higher than post-

partum…ie. CHO oxidation higher
during pregnancy
Probably due to fetal utilization of

glucose (approximately 20-25 g/d)
Behavioral Changes
Behavioral Adaptations to
Pregnancy:
Dietary Intake
Do pregnant women need to increase

energy intake?
By how much?
When?
Behavioral Adaptations to
Pregnancy:
Physical Activity
Do pregnant women need to change

patterns of physical activity?
When?
By how much?
Behavioral Adaptations
Need for 80,000 kcal positive balance

over pregnancy
Consider in terms of energy balance

equation
Need to consider all sources of energy

expenditure together
Energy Balance in Pregnancy
80,000kcal =
Dietary Intake REE
↑ glucose production Physical Activity
Insulin resistance - TEF
Stored energy (fat)
↑ nitrogen retention
Energy Balance in Pregnancy
Many ways to achieve positive energy balance

 Increasing dietary intake
 Metabolic alterations of pregnancy
 Changes in metabolic rate
 Changes in physical activity energy expenditure
Which occur depend on fetal needs,

prepregnancy energy status, living conditions
Energy Balance in Pregnancy:
Examples
Underweight women, fixed dietary intake,

fixed (higher) level of PA
 Only possible changes are enhanced metabolic

changes of pregnancy (limited) and ↓ BMR
 May permit continuation of pregnancy, but

compromise fetal growth
Examples
Overweight women:
 Pre-existing fat stores, increased dietary

intake, decreased physical activity
 Greater increase in BMR (about 20%) ? to

offset further fat accumulation
Normal
Normal weight women:
 Variable increase in dietary intake

 Metabolic alterations of pregnancy
 Increases in BMR throughout pregnancy (esp.
later)
 Variable decreases in physical activity
170000 kcal
60000
kcal
Recommendations for
Pregnancy
Second trimester: additional 340 kcal/day

Third trimester: additional 452 kcal/day
Appropriate intakes monitored by weight

gain during pregnancy
Weight gain recommendations vary with

pre-pregnancy weight status
Table 4-16, p.89
Fig. 4-8, p.89
Table 4-17, p.92
Monitoring Weight Gain During
Pregnancy
Optimal weight gain dependent on pre-

pregnancy weight
 First trimester 3-5 lb total
 Normal & underweight 0.5 lb/week 2nd trimester

0.75 lb/week 3rd trimester
 Overweight 0.5 lb/week 3rd trimester

Weight Gain During Pregnancy
 Increased risk of adverse fetal outcome

with lower weight gain – eg. preterm
delivery
 Increased maternal weight retention if

weight gain >1.5 lb/week
Fig. 4-10a, p.91
Iron & Pregnancy
Fluid Changes
Plasma volumes begin increasing from

conception, RBC volume increases less →
“hemodilution” effect.
Most marked 10-20 weeks
Fluid requirements met by ↑ thirst, need for

Fe for RBC synthesis
Iron and Pregnancy
Substantial requirement for iron during

pregnancy due to increased utilization:
 450 mg to increase RBC mass

 300 mg for fetal/placental use
 250 mg lost at delivery (blood loss)
Additional 1000 mg required to meet

needs
Determining Iron Status
Physiological increase in plasma volume as well
as RBC means Hgb changes throughout
pregnancy
 Normals >110 g/l during 1st and 3rd trimesters

>105 g/l during the 2nd trimester (maximum
volume increase)
 Could also evaluate other markers eg. ferritin

Risks of Iron Deficiency
2-3 x ↑ risk of preterm delivery/ low

birthweight
Lower intelligence, language, gross
motor, attention tests (5 years)
Low iron stores to fetus, risk of iron
deficiency anemia
Decreased maternal reserves
Iron Supplementation
The larger the dose, the less the absorption

Less absorption taken with food, or other
supplements
Increasing absorption as pregnancy
progresses
Side effects: nausea, cramps, constipation,
gas
? Adverse effects of “excess” iron
Fig. 4-18, p.105
Usual practice: 30 mg supplement

week 12 +
 Require additional 3.7 mg/d absorbed Fe +
1.8 usual = 5.5 mg/d
 20% absorption of 27 mg dose = 5.5 mg
Fe deficiency: 60-180 mg/d

Supplementation
and Anemia
WHO definition of severe anemia:
Hemoglobin < 7 g/dL
Level of risk
 Moderate anemia (Hgb 7–11 g/dL): Not
increased
 Severe anemia: Significant risk
Severe anemia associated with:
 Low birth weight newborns
 Premature newborns
 Perinatal mortality
 Increased maternal mortality and morbidity
Anemia and Obstetrical
Hemorrhage
Anemia does not cause obstetrical hemorrhage (even
severe anemia)
Etiology of obstetric hemorrhage
 Early pregnancy: Abortion complications
 Mid/late pregnancy to delivery: Previa, abruption,
atony, retained placenta, birth canal laceration

Primary factors affecting outcome:
 Rapid intervention to prevent exsanguination
 Availability of skilled provider, drugs, blood and fluids
There is no evidence that high levels of hemoglobin are

beneficial in withstanding a hemorrhagic event.
Enkin et al 2000; Mahomed 2000a.

Iron requirements:
 Average non-pregnant adult:
 800 µ g iron lost/day

 + 500 µ g iron lost/day during menses
 Pregnant woman: Increased need
 Expanded blood volume

 Fetal and placental requirements
 Blood loss during delivery
Routine vs. selective iron supplementation:
 Prevalence of nutritional anemia
 Routine iron and folate supplementation where nutritional
anemia is prevalent
 Recommended dose: 60 mg elemental iron + 5 µ g folic
acid
Mahomed 2000b; WHO 1994.

Folic Acid
Strong evidence that folic acid prevents
preconceptionally recurrent and first occurent neural
tube defects
Increasing evidence that folic acid reduces risk of some
other birth defects
Improves the hematologic indices in women receiving
routine iron and folic acid
USPHS/CDC recommends for US women
 400 µ g/day: All women in childbearing age
 1 mg/day: Pregnant women
 4 mg/day: Women with history of neural tube defect
deliveries take folic acid 1 month prior to conception

and during first trimester
Czeizel 1993; Czeizel and Dudas 1992; Mahomed et al 1998; MRC Vitamin Study
Research Group 1991.
Neural Tube Defects
Failure of closure of the neural tube
during early development
Various presentations, mechanisms

unclear
Most common congenital anomaly in

US & Canada (1/4000 live births in US)
Neural Tube Defects –
Clinical
“Lump” may have nervous tissue,
never normal
Control of muscles distal (below)

defect affected – often lower limbs,
bladder
If defect high, may cause death

The Folate Story
NTD assumed due to genetic +
environmental causes
More common in low SES families –

nutrition obvious potential cause
1976, Smithells reported low vitamin

levels in women delivering babies with
NTD
Folate story - 2
1983 – reported 86% decrease in NTD in
multivitamin supplemented women – not
randomized
1991 and ’92 – randomized, controlled
trials showing decreased risk of NTD
with folate alone or multivitamin
Studies began to establish mechanism
Folate – what we know
Periconceptional folate may lower
incidence of NTD by 70%
Plasma homocysteine levels

slightly higher in affected mothers
Homocysteine may be teratogenic

(toxic) in embryo culture
Folate – Metabolic
Functions
“family of compounds”
Active in cytosol and mitochondria
Transfer of 1-carbon compounds
needed in the formation of amino
acids, purines and pyrimidines and
S-adenosylmethionine (SAM)
MTHFR
Folate Metabolism & NTD
Mutations of MTHFR shown to be
associated with increased risk of
NTD
Frequency of mutant allele in

ethnic groups roughly correlates
with incidence of NTDs
Final Word: Folate and
NTDs
Strong evidence that increased
folate intake associated with
reduced NTDs
Mechanism probably complex –

interaction between genes (more
than 1?), environment, nutritional
status (eg vitamin B12 status)
Folate Requirements
Dietary Folate Equivalents

 1 µ g food folate
 0.6 µ g synthetic folic acid with food
 0.5 µ g synthetic folic acid empty
stomach
Folate Requirements
(adult females)
EAR: 320 DFE/day
RDA: 400 DFE/day
TUL (synthetic folic acid only): 1000
µ g/d
Periconceptional: 400 µ g synthetic

folic acid/d (+200 µ g from diet)
Sources of Folate
Naturally occurring folate:
 Vegetables (peas, beans, asparagus,
greens)
 Fruits (oranges, orange juice, pineapple
juice)
Fortified foods:
 Bread and grain products (0.15 mg folic
acid /100g flour, 0.2 mg/100g pasta)
Folate Toxicity
Minimal risk
May mask anemia associated with
Vitamin B12 deficiency, ?exacerbate
neuropathy
Iodine Supplementation
Iodine deficiency is a preventable cause of mental impairment
Iodine supplementation and fortification programs have been
largely successful in decreasing iodine deficiency conditions
Population with high levels of mental retardation (e.g., some
parts of China):
 Supplementation may be effective at preconception up to
mid-pregnancy period
 Form of iodine supplementation (iodinating food or
oral/injectable iodine) depend on:

 Severity of iodine deficiency
 Cost
 Availability of different preparation
Enkin et al 2000; Mahomed and Gülmezoglu 2000.

Vitamin A
Indications for vitamin A supplementation:
 Vertical transmission of HIV (ongoing)
 Infant survival
 Maternal anemia: Positive interaction with iron in reducing
anemia
 Infection
 Maternal mortality:
 Vitamin A vs. placebo RR 0.60 (0.37–0.97)

 Beta-carotene vs. placebo RR 0.51 (0.30–0.86)
Potential adverse effects of Vitamin A and related substances:
 Total daily dose > 10,000 IU before 7th week of gestation
associated with birth defects: craniofacial, central nervous

system, thymic cardiac
Overall effectiveness and safety of vitamin A supplementation
needs to be evaluated
Rothman et al 1995; Suharno et al 1993;

West et al 1999.
Vitamin A: Mechanism of
Action
Generally obtained from diet as
Vitamin A (retinol, animal sources)
or provitamin A (carotenoids, plant
sources)
Metabolites of Vitamin A taken up
by specific nuclear receptors,
influence transcription
Vitamin A & Embryonic
Development
At least 3 mechanisms of control:
Pathways produce different products
different receptors expressed in specific

regions at specific times, sensitive to
specific concentrations
Appropriate concentrations partly

regulated by activity of pathways of
synthesis & catabolism
Vitamin A & Development
“Sensitive” tissues: tissues shown

to have specific patterns of
receptors/enzymes to regulate
retina, spinal cord, brain, heart,

somites, thymus
Vitamin A Deficiency
Animal dietary deficiency studies:

abnormalities of eye, heart, lung,
urogenital systems
Knockout models: death,

abnormalities
Vitamin A Deficiency
Human congenital abnormalities

uncommon, even in areas of
endemic Vitamin A deficiency –
reason?
Documented: abnormalities of eye,

lung, heart
Vitamin A Toxicity
Animal studies: CNS, facial,
cardiovascular, thymus
Humans: Best documented in
women treated with 13-cis-retinoic
acid (Accutaine) for acne – similar
clinical findings
Critical period: 1st trimester – week
2-5
Vitamin A Requirements
Retinol equivalents (RE): 1 RE = 1

µg retinol = 6 µg β carotene
RDA: 800 µg retinol
No change during pregnancy

Vitamin A Safety
“safe” level not known
WHO recommends daily supplement

not more than 3000 RE
May be cumulative dose that

determines toxicity - storage
β Carotene: Safety
Theoretically 1 β Carotene→2 retinoids
30% intestinal absorption
50% of absorbed converted to

retinoids
β Carotene: Safety
Animals: Extremely large doses not
teratogenic
Humans: Case reports not teratogenic
? Serum retinol regulates conversion of β

Carotene to retinoid
Other Micronutrients:
Calcium
Association between reduction in pregnancy induced
hypertension (PIH) and calcium supplementation
 Reduction of incidence of PIH
 Routine supplementation likely beneficial in women
at high risk of developing PIH or have low dietary

calcium intake
 High calcium doses (2 g/day) not associated with
adverse events
 Need adequately sized and designed trials in
different settings to confirm beneficial effects

Recommend increase in calcium intake through diet in
women at risk of hypertension or low calcium areas
Bucher et al 1996; Kulier et al 1998; Lopez-Jaramillo et al 1997.

Calcium Supplementation:
Objective and Design
Objective: To assess effects of calcium in prevention of
hypertensive disorders of pregnancy
Methods: Meta analysis of randomized controlled trial
Outcomes:
 Mothers: Hypertension +/- proteinuria, maternal death
or serious morbidity, abruption, cesarean section,

length of stay
 Newborns: Preterm delivery, low birth weight/small for
gestational age, neonatal intensive care unit admission,

length of stay, still birth/death, disability, hypertension
Atallah, Hofmeyr and Duley 2000.

Results
Mothers:
 Hypertension+/-proteinuria:
 Less hypertension: RR 0.81 (0.74–0.89)
 Less pre-eclampsia: RR 0.70 (0.58–0.83)
 Better if low calcium intake, high risk
Newborns:
 Low birth weight: RR 0.83 (0.71–0.98), best
for women at highest risk
 Chronic hypertension: RR 0.59 (0.39–0.91)
 No difference in preterm delivery, neonatal
intensive care unit admission, stillbirth, death

Conclusions
Calcium decreases risk of hypertension, pre-eclampsia,
low birth weight, and chronic hypertension in children
Recommend for high risk women with low calcium
intake, if pre-eclampsia is important in the population
Calcium has other health benefits not related to
pregnancy:
 Maintaining bone strength
 Proper muscle contraction
 Blood clotting
 Cell membrane function
 Healthy teeth

Summary of Nutritional
Review Findings
Evidence of nutritional intervention
effectiveness
 Iron supplementation
 Periconceptional folic acid intake
 Iodine use
 Balanced energy/protein supplementation
 Calcium
Confirmatory studies to examine
effectiveness
 Vitamin A
 Zinc
Foods to Consume During
Pregnancy
3 to 4 Milk/Dairy
Products
3 protein-rich foods
Folic acid-rich foods,
such as orange juice
Iron-rich foods, such
as red meats (beef),
spinach
A total of 5 fruits &
vegetables daily
Other Guidelines During
Pregnancy
Decrease fats and sweets
Try to gain no more than 24 lbs.
Eliminate alcohol and other drugs,
including caffeine
Teens who are pregnant are still
growing and need to especially be
concerned with protein, iron,
calcium, vitamin A and C intakes.
Lactation
Physiology of lactation
Changes during
pregnancy
 Increased breast tissue
 Maturation of structure
Hormonal controls
 Prolactin: stimulates milk
production
 Oxytocin: stimulates milk
release
 “let-down” reflex
Breast Structure
Composed of glandular tissue, supporting

connective tissue and protective fat
Glandular tissue: collection of independent

glands
15-25 glands arranged like spokes of wheel

around breast
Breast Structure - 2
Each gland (lobe) is treelike structure:

 Lactiferous sinus → Lactiferous duct →
Lobule (20-40) → Alveoli (10-100)
Alveolus is secretory unit; surrounded

by myoepithelial cells (muscle)
Surrounded by fat, connective tissue,

blood vessels, lymphatics & nerves
Connective tissue
septa
Mammary fat
The Breast in Pregnancy
Early pregnancy: ↑ ducts, branching, lobules
 Triggered by hormones of corpus luteum and placenta:

HCG, HPL, prolactin (anterior pituitary), estrogen
(glands), progesterone (ducts)
 Estrogen & progesterone key in increasing arborization
 Prolactin develops secretory cells at ends of ducts

Lactogenesis
3 stages:
 Stage I: Occurs in 3rd trimester – increases
in lactose, protein, immunoglobulin in gland
 Stage II: 2-5 days post-partum – increased
blood flow, O2 and glucose uptake – “milk
comes in”. Milk composition variable.
 Stage III: 10 days – “mature milk” Milk
composition stable.
Milk Formation
“Raw materials” supplied by maternal

circulation
May be simply transported into milk or

“processed”
Final product secreted into ducts in centre

of cluster of alveoli
Milk Formation
Golgi apparatus, endoplasmic reticulum

important in triglyceride, protein,
lactose synthesis
Plasma proteins, immunoglobulins (IgA)

transported through alveolar cell
Water, electrolytes pass through by

passive diffusion
Lactation
Nutrition for breastfeeding women
 Energy and protein
 Higher needs than pregnancy
 Vitamins and minerals
 Most are higher or same as pregnancy
 Iron and folate needs are lower
 Water
Food choices
Practices to avoid while breastfeeding
 Alcohol, drugs, smoking, excess caffeine
Lactation
Benefits of breastfeeding
 Benefits for infants
 Optimal nutrition
 Reduced incidence of
respiratory, GI, ear infections
 Convenience
 Other benefits
 Benefits for mother
 Convenience
 Enhanced recovery of uterus size
 Other benefits
Contraindications to breastfeeding
Lactation vs Breastfeeding
Lactation: the production of milk; the

period following childbirth when milk is
formed in the breasts
Breastfeeding: the process of

nourishing an infant at the breast
Initiation of Lactation
At delivery of placenta, abrupt ↓ in HPL,

estrogen and progesterone
Removal of estrogen and progresterone

are trigger for milk secretion
Prolactin levels rise from early pregnancy

(develop secretory portions of gland).
Continued stimulation by suckling
Maintenance of Lactation
Prolactin levels high in first weeks, gradually

decline, rise with suckling
Suckling also trigger release of oxytocin from

posterior pituitary – triggers contraction of
myoepithelial cells to permit milk-ejection
Poor relationship between prolactin levels and

volume of milk produced
Initiation & Maintenance of
Lactation: Summary
Removal of estrogen &

progesterone at delivery stimulus for
milk secretion
Prolactin rises throughout pregnancy

and remains high with suckling –
important in establishing lactation
Oxytocin released from posterior
pituitary (stimulus: suckling) causes
milk ejection (“letdown reflex”)
Breast Milk: Composition
Composition highly variable:

 Immediate post-partum vs “mature”
 AM vs PM
 Early in feed vs later in feed
Nutrient composition reflects average of

stable composition
Colostrum
Earliest milk (day 1-3)
Yellow color, low volume (2-10 ml/feed)
lower energy, higher protein (sIgA,

lactoferrin), cells
Adequate to meet infant needs in first 3 days
Breastmilk Composition: Protein
∼ 10 grams/l protein; 20% non-protein

nitrogen (eg urea, FAA)
Qualitatively different from cow’s milk

 Cow’s milk 70 casein; 30% whey
 Human milk 18% casein; 82% whey
Whey soluble in acid, more easily digested,

more rapidly emptied from stomach
Breastmilk Composition: Lipid
∼ 50% calories from lipid, mostly long chain fat
Lipid contained in milk-fat globule – protein carrier for

triglycerides
Most variable component of breast milk, but quantity does

not change with diet
Qualitative changes with diet – contains ARA, DHA (not

found in cow’s milk)
Breastmilk Composition: CHO
Virtually 100% as lactose
Approximately 40% energy content of breastmilk

Breastmilk Composition:
Micronutrients
 Ca, PO4 lower than cow’s milk, but very bioavailable;

stable throughout lactation
 Fe content ↓ throughout lactation, but very

bioavailable – does not meet infant requirement
past 6 months
 Vitamin K – usually synthesized by intestinal flora.

BF infant inadequate synthesis, low in breast
milk. All infants receive Vitamin K at birth
Breastmilk Composition:
Micronutrients
Vitamin D
 ∼ 22 IU/l, fairly constant throughout
pregnancy
 Likely inadequate to meet needs, especially
in dark skinned, covered individuals,
northern latitudes
 Supplementation recommended
Supplements for Breast-fed
Babies
REQUIRED NOT REQUIRED

 Vitamin K 1 mg IM @  Water
birth
 Other milks
 Vitamin D – 400 IU/d
 Fe (dietary) after 6  Multivitamin
months age supplements
 Fluoride after 6
months if water <0.3
ppm (0.25 mg)
Breastmilk Composition: Other
Immunoprotective substances
 Secretory IgA – line mucosal surfaces, prevent
microbial attachment
 Lactoferrin – antimicrobial activity
 Lysosyme – cleaves bacterial cell walls
 Lymphocytes – cytokine production
Hormones – cortisol, insulin, thyroid

hormone
Growth factors - EGF
Advantages of Breastfeeding
Infant:
 Safety – microbiological/ compositional
 Ideally suited to infant growth/development
needs
 Immunological protection
 ?lower incidence of chronic diseases eg.
Crohn’s disease, diabetes, allergy
 Maternal-infant bonding
 ?IQ – benefits beyond the period of
breastfeeding
Advantages of Breastfeeding
Maternal:
 Cost
 Availability
 Post-partum weight loss, uterine involution
 Delayed return of fertility
 Decreased incidence of pre-menopausal
breast cancer +/- ovarian cancer
 ? Protective against osteoporosis
 Maternal-infant bonding
Breastfeeding
Basic principles:
 Breastfeeding will ideally begin during the alert
period immediately after delivery
 Babies should be fed “on demand” rather than by
schedule
 Typical newborns will feed 8-12 x /24 hours
 Babies should be offered 1st breast until finished,
then offered 2nd breast
 Breastfeeding should continue for at least 6
months, ideally 12 months
Breastfeeding: The Art
Infant cues recognized early – ie hands to

mouth, head movement
Infant facing mother “tummy to tummy”
Tickle lower lip with nipple to open mouth
Breast deeply into mouth – tip of nipple at

junction of hard & soft palate
Breastfeeding: The Art
Initial few sucks quick, irregular
When “letdown” induced, sucking

becomes slow, rhythmic
 Suck, swallow, breathe pattern
Active feeding 5-20 min (maximum 30

min)
 Babe releases breast spontaneously
How Do I Know if There’s Enough
Milk?
Weight gain
Stools – at least 3-4 yellow seedy BM/d
Urine clear, light colored, 6 x/day
Breasts full prior to feeding, soft
afterwards
Baby settled and comfortable for 2-3
hours after feed
Contraindications to
Breastfeeding
Drugs of abuse
A few other drugs (check any drug with current info)
Chemotherapy
Radioactive isotopes (tests) – only temporarily
Maternal infections
 HIV
 Active TB (until on treatment and non-infectious)
Galactosemia
Infancy
Growth is the best marker of
nutritional status
 Evaluated using growth charts
Weight gain
 Double birth weight by 4-6 months
 Triple birth weight by 12 months
Length gain
 Increase length by 50% by 12 months
Head circumference
Section 2 Infancy nutrition
Energy and nutrient needs of infants
 Requirements based on composition of breast milk
 Energy
 Highest needs of any life stage
 Protein
 Highest needs of any life stage
 Carbohydrate and fat
 Fat: major energy source
 Carbohydrates: simple sugars
 Water
Infancy
Energy and nutrient needs of
infants
 Key vitamins and minerals
 Feeding infants
 Breastfeeding
 Infant formula
Photo © PhotoDisc
Advantages of Breast
Feeding
Increased IQ
Bonding between
mother and infant
Breast milk provides
antibodies to infant
Convenient and
saves money
Breastfeeding is Best
Only breastmilk offers infants

and young children complete
nutrition, early protection
against illness, and safe,
healthy food—all at once:
Lowers risk of death both in
infancy and early childhood.
Promotes healthy growth and
development.
Protects against certain
infectious diseases.
May protect against chronic
diseases.
Saves families money.
Has health benefits for
mothers.
Breastfeeding
Advantages
 Faster gastric emptying: whey fraction is more
easily digested
 Host Defense: Whey protein is a lacto-albumin
with lactoferrin, lysozyme, IgA – line GI tract
 IgG in human breastmilk leading to decreased
incidence of GI illness, Respiratory illness, Otitis
Media
 Decreased food allergies, decreased atopic
conditions
 Maternal/Infant bonding
 ECONOMICS
Feeding Infants: Breastmilk
vs. Formula
Breastmilk Formula
 Protein: whey: casein  Protein: whey: casein
ratio 60:40 ratio may be
manipulated to 60:40
 Iron fortified
 Iron: less total iron, but
increased absorption
 Carbohydrate
 Carbohydrate sources: sources: lactose
lactose, glucose,
oligosaccarrhides
 Fat: polyunsaturated,
 Fat: human milk fat, monounsaturated,
cholesterol and saturated; oils
Health Benefits for
Breastfeeding Women
Postpartum Reduces Bone Health
Benefits Cancer Risks -Greater bone
-Helps to expel -Epithelial density among
the placenta Ovarian Cancer women who have
-Reduces blood -Breast Cancer ever breastfed
loss -Lower risk of hip
-Speeds uterine fracture later in
involution life
-Helps body
weight return to
normal
Breastfeeding
Disadvantages
 Anatomy such as inverted nipples
 Difficult to stimulate baby to feed
 Breast engorgement
 Soreness of nipples
 Local tenderness: “plugged” alveolar ducts
 TIME
 Back to work. . .
What Is Optimal
Breastfeeding?
Begin breastfeeding at birth.
Breastfeed exclusively for

an infant’s first six months
of life.
Starting at six months,

breastfeed with
complementary feeding to
age two or longer.
While a growing percentage of infants are
breastfed, only a minority are breastfed in
optimal ways…
Average Unweighted Range Among No. of

Percentage of Average Among Countries Countries
Infants Countries with Data
Breastfed…
Ever 96% 86%-99% 65
Within 1 hour 41% 3%-81% 65
after birth
Exclusively up 38% 1%-79% 47
to 3 months
Exclusively up 31% <1%-90% 57
to 6 months
At Least 2 years 40% 5%-89% 42
A Call to Action
WHO and UNICEF Global Strategy for Infant and Young Child Feeding:
Health Care
Communities
Services
National International
Governments Donors
Applies lessons learned about breastfeeding to better enable

and support women to breastfeed optimally.
Bottlefeeding
Other family members can help feed infant.

Formula should be used during first year.
Formulas come in powder form, concentrated,
or ready-to-use.
Sterilize bottles until child is 6 months old.
Begin cow’s milk after one year old.
Bottle Feeding Techniques
 Always hold baby

 Support head
 Tip bottle so milk fills nipple
 Wait for baby to stop
eating to burp
Infancy
Introduction of solid foods
 Readiness for solids
 Increased digestive enzymes
 Loss of extrusion reflex
 Able to sit without support
 Age of about 4-6 months
 Feeding schedule
 Baby rice cereal
 Strained fruits, vegetables, meats
 Add one food at a time
Adding Solid (Baby) Foods
Wait unit infant is 4 to 6
months old to add baby
food.
Begin with rice cereal,
then vegetables, fruits,
and later meats.
Avoid orange juice and
eggs until 9 months old.
Avoid soft drinks, and
foods which might cause
choking (raisins, nuts,
popcorn)
Section 3
Nutrition for the Toddler and
preschooler
For ages 1 to 3, portion

sizes should equal 1
tablespoon for every
year of age.
Cut up meats into bite-
size pieces.
3 to 4 ½ cup servings
of dairy daily.
Serve them colorful
fruits and vegetables.
5 servings per day.
Toddler and Preschooler
Nutrition
Toddler eating behaviours – children of this age are often
erratic eaters. They love food one day and dislike it the next,
or the meal they refused at home is happily eaten away from
home.Toddlers also have changeable appetites. Growth spurts
and differing activity levels during the day can result in a large
appetite for a while followed by small and picky eating.
Generally toddlers enjoy eating with family and friends and
helping with simple meal preparation.
Preschool age children – once children commence preschool

life takes on a new routine. A regular intake of food is needed
throughout the day to give children stamina and help their
concentration. Some children in this age group as still fussy, so
they need to be offered a wide variety of foods and regular
meals and snacks.
Table 1 - What are the
common characteristics?
Preference for foods consumed by parents and
friends
Reluctance to try new foods
Variable appetite related to decreased growth
velocity
Independent feeding
Grazing, may not appear to eat much at any
one time
Fussy with food, food ‘fads’ common
Food refusal common, tantrums common
Table 2 – Common toddler
feeding problems
Meal-time tantrums
Bizarre food habits
Multiple food dislikes
Prolonged reliance on pureed foods
Delay in self-feeding
‘Pica’ – eating non-food items
Overeating; difficulty in recognising when full
Delay or difficulty in chewing
Under-intake of food (excessive reliance on
drinks)
Slower growth
The growth of a typical toddler or
preschooler is much lower than
that of babies.
Young children need small,
frequent meals and snacks due to
the small size of their stomachs.
Feeding patterns
Young children enjoy becoming
independent eaters.
Toddlers are commonly
described as ‘grazers’,
preferring small, frequent
meals and snacks.
Food preferences
Food preferences and eating habits
seem to be formed early in life, but
are also easily changed at this age.
Young children may appear to become
fussier, and have many food dislikes,
even to foods previously enjoyed.
Table 3 – Practical toddler
feeding strategies
Sit with the child during meals and snacks
Encourage the child to eat family meals
Continue to offer foods even if they initially may be refused
Try not to use food as a reward, punishment or pacifier
Talk pleasantly to the child at meals but not just about food
Use meal times to give some nutritional education
Avoid other distractions at mealtimes such as the television
or talking on the phone
Table 3 – Practical toddler
feeding strategies
Allow simple decision making regarding choice eg
“do you want a pear or a plum?”
Find something positive about each mealtime
Allow the children to serve themselves by placing
food in the centre of the table with serving
tongs
Encourage children to taste the food offered
Do no hurry the child to eat
Do not force the child to have some of everything
before allowing another serve of a particular food
• Don’t force the child to eat all the food offered
Nutrition for Childhood
Children, ages 3-8
need about 1700
cal./day
Require high-quality
protein for growth
Serve a breakfast with
a carbohydrate food &
a small amount of fat
Serve healthy snacks
Nutrition for Teens: Ages
14 to 18
Needs vary with growth,
gender and activity level
Females require about
2300 cal./day
Males need about 3100
cal./day
Choose food carefully
including 3 well-balanced
meals daily
Section 5
NUTRITION in Adolescence
Healthy People 2000
Reduce coronary heart disease to no

more than 100 per 100,000 people
➲Baseline: 135 per 100,000 in 1987
Reverse the rise in cancer deaths to
achieve a rate of no more than 130
per 100,000
➲Baseline: 133 per 100,000 in 1987
Healthy People 2000
Reduce overweight to a prevalence

of no more than 15% in adolescents
12 through 19 years
Reduce dietary fat intake to an
average of 30% of calories or less
(baseline = 35%)
Reduce saturated fat intake to less
than 10% of calories (baseline 13%)
Generalities
Diseases such as coronary heart

disease, certain types of cancer,
stroke, diabetes mellitus, and
atherosclerosis may have their roots
in childhood
Habits originating in adolescence
may persist into adulthood
Early dietary modification has been
recommended
Generalities
Nutrition influences growth and

development throughout infancy and
childhood
Nutrient needs are greater during
adolescence than any other period
after birth
Failure to consume and adequate diet
can disrupt normal growth and
development
Nutrient Requirements -
Energy
Energy needs for individual
adolescents vary according to:
Sex
Age
body size
pubertal development
physical activity
Energy
The recommendations for energy
are estimated from average
energy intake related to average
body weights
A sedentary teenager may gain
excess weight by consuming fewer
than the recommended amount of
calories or vice versa
Energy
An active adolescent may require a
higher caloric intake to maintain
adequate weight gain
Energy
National surveys show energy
intakes below the RDA for:
girls age 12-17
older boys
Blacks
adolescents from economically
deprived families
Energy
It is not clear whether these low
dietary intakes are reflective of
decreased energy needs secondary
to:
➲low physical activity
➲food restriction due to economic
limitations
➲intentional dieting
Energy
Some reports suggest that the prevalence
of obesity among children and adolescents
is increasing
Some studies suggest that there are an
equal number of overweight and overweight
adolescents (around 25% for each)
Nutritional dwarfing (ND) and dynamic
obesity are not common (both around 1%)
Energy RDA - Adolescents
➲Males 11-14 yrs 55 kcal/kg

➲Females 11-14 yrs 47 kcal/kg
➲Males 15-18 yrs 47 kcal/kg
➲Females 15-18 yrs 40 kcal/kg
➲Pregnant 11-14 yrsExtra 500 kcal/d
➲Pregnant 15-18 yrsExtra 400 kcal/d
Protein
The need for protein rises during
adolescence
However, the median intakes of
protein are well above the
recommended level
➲ even for children from economically
disadvantaged families
Protein
If energy is limited dietary protein may be
catabolized and growth may be
compromised even though the protein
intake per se does not appear deficient
Protein supplements are rarely necessary
to improve either protein quality or
quantity
There is no proven effect of athletic
performance with increased protein intake
Protein RDA - Adolescents
➲Males 11-14 yrs 1.0 g/kg

➲Females 11-14 yrs 1.0 g/kg
➲Males 15-18 yrs 0.85 g/kg
➲Females 15-18 yrs 0.85 g/kg
➲Pregnant 11-14 yrs 1.7 g/kg
➲Pregnant 15-18 yrs 1.5 g/kg
Carbohydrates & Fats
Current recommendations for dietary

carbohydrate and fat intake relate to
nutrient type and percentage of daily
calories
Nutrient Requirements
Adolescents should consume diets with:
➲less than 30% of calories from fats
➲less than 10% of calories from saturated fat
➲300 mg cholesterol
➲55% of calories should be from carbohydrates
➲emphasis should be on foods rich in complex
carbohydrates & fiber
Typical adolescent diet:
➲36% of calories from fat
➲13% is from saturated fat
➲complex carbohydrate and dietary
fiber intake are low
➲simple sugars are high
Some adolescents limit their fat intakes
resulting in dietary inadequacies or
nutritional dwarfing
➲Fat is the most concentrated source
of energy
➲Restricting fat intake may lead to
inadequate energy consumption
Reduction of animal fat intake may lead to
inadequate energy consumption
Animal products (meat, eggs, etc.) are
excellent sources of iron and zinc
Increasing complex carbohydrates will
replace energy but not the iron and zinc
A vegetarian must consume diets with fruits,
vegetables, and whole grains
Vitamins
The need for vitamins and minerals
rises during adolescence
A greater energy demand means the
following will be necessary for the
release of energy from carbohydrates:
➲More thiamine
➲More riboflavin
➲More niacin
Vitamins
Increased tissue synthesis means a
greater demand for the substances
that are needed for DNA and RNA
metabolism:
➲Folacin
➲Vitamin B12
Vitamins
Rapid rate of skeletal growth
means a need for:
➲Vitamin D
Vitamins
An increase in the following
substances are needed to maintain
structural and functional properties
of the new cells attained during
growth:
➲Vitamin A
➲Vitamin C
➲Vitamin E
Minerals
The need for minerals increases
substantially during the growth spurt
of adolescence
➲Calcium for increased skeletal mass
➲Iron for expansion of blood volume
➲Zinc for the generation of skeletal
and muscle tissue
Vitamins & Minerals
Most likely to be inadequate during
adolescence are:
➲Iron
➲Calcium
➲Vitamin A
Iron
Iron deficiency is the most prevalent
dietary deficiency in:
➲Older adolescent girls
➲Lower socioeconomic groups
➲Pregnant teenagers
➲Vegetarian teenagers
➲Athletes who have increased iron losses
Iron
Iron deficiency during adolescence
is partly related to rapid growth
Sharp increases in lean body mass,
blood volume, and red cell mass
increase iron needs for:
➲myoglobin in muscle
➲hemoglobin in blood
Iron
Iron deficiency is more common
during peak growth in boys
It is more common in teenage girls
due to iron loss from:
➲Menstruation
➲Decreased dietary intake
Iron
Adolescents should be encouraged to eat:
➲Iron-fortified breads and cereals
➲Other iron rich foods
The bioavailability of nonheme iron from plant
foods can be enhanced with vitamin C
Pregnant teens should take iron supplements
Calcium
Calcium tends to be low in

adolescent diets
RDA is 1200 mg/d
➲Bone mass achieved during
adolescence and young adulthood
may decrease the risk of
osteoporosis during later life
Calcium
Calcium intake is particularly
important for women
➲Median calcium intake for
adolescent girls is typically about
400 mg below the RDA
Boys tend to match their calcium
requirements closely
Calcium
Teens tend to drink less milk in favor of
carbonated drinks
Carbonated drinks tend to increase the
phosphorus to calcium ratio and may
further compromise calcium balance
Blacks tend to consume less calcium but
due to genetics have larger bones and
less risk of osteoporosis
Alcohol
Is a source of calories
Replaces more nutrient dense
foods
Tends to provoke deficiencies in:
➲folic acid
➲thiamin
➲pyridoxine
Adolescent Eating
Practices
Common eating practices of
adolescents include:
➲eating away from home
➲skipping meals
➲snacking
☛Breakfast is the most common
meal missed by adolescents
Adolescent Eating
Practices
Over 90% of adolescents eat
snacks
Snack foods (junk foods) are
typically:
➲high in fat
➲high in sugar
➲high in sodium
Adolescent Eating
Practices
Only 39% of adolescents report eating
nutritious snacks
Adolescents have energy requirements
which require high calorie snacks
Snacks provide up to one third of
adolescents daily energy intake
Reducing nutritious snacking can result in
poor weight gain and growth
Adolescent Eating
Practices
➨ Wisely chosen
snacks can be a
potential asset to an
adolescent’s diet
Adolescent Eating
Practices
Adolescents commonly eat “fast foods”
➲These tend to be high in total and
saturated fats
➲Also high in cholesterol and sodium
The need is to supplement the higher fast
foods with fresh fruits and vegetables
Dieting
Adolescence is characterized by a heightened

awareness of physical appearance
Dissatisfaction with body weight or body
image is widespread in adolescence
Males are concerned with physical
development
Females are concerned with body weight
Dieting
61% of adolescent girls report

dieting during the previous year
28% of adolescent boys report
dieting during the previous year
➲51% report fasting
➲16% used diet pills
➲12% report vomiting
Dieting
Dieting concerns have been even

described in school-age children as
well as very young adolescents
Excessive dieting may disrupt
normal growth & development
One survey of 325 female
adolescents revealed excessive
concern with obesity regardless of
body weight
Dieting
Over half of underweight

adolescents reported being terrified
about becoming overweight
36% described a preoccupation
with body fat
Caloric restrictions of 55% to 69%
are not uncommon
Eating Disorders
Anorexia Nervosa
➲Relentless pursuit of thinness
➲Weight deficits
➲Distorted body image
➲Amennorhea
➲Incidence is 0.3% to 0.5%
Eating Disorders
Bulimia
➲Frequent binging
➲Purging
➲Vigorous exercise
➲Strict dieting
➲Laxatives
➲Diuretics
Complications of Anorexia
Nervosa and Bulimia
Cardiovascular abnormalities
Electrolyte disturbances
Malnutrition
Reduced body mass may contribute
to bone deficit
➩The worst complication: 15% to
30% will remain chronically ill
Adolescent Obesity
15 to 30% of adolescents in America

are obese
This rate has increased over the
past 20 years
The correlation between childhood
and adult obesity increases with the
duration and degree of obesity and
its persistence into adolescence
Adolescent Obesity
14% of overweigh babies go on to

develop adult obesity
Obesity that persists through age
12 raises the odds of adult obesity
to 4:1
Weights of adopted children
correlate better with biologic rather
than adoptive parents
Adolescent Obesity
Monozygotic twins exhibit more similarity in

weight, body shape, and fat deposition than
dizygotic twins
Television viewing has been directly related
to prevalence of obesity due to its sedentary
nature and the consumption of high energy,
low nutrient foods while viewing TV
Adolescent Athletes
In attempts to optimize
performance, adolescent athletes
may become susceptible to many
nutritional misconceptions
Many believe that vitamin, mineral
or protein supplements will
increase athletic performance
This does not work
Adolescent Athletes
Athletes who seem to be at

greatest risk are:
➲wrestlers
➲ballet dancers
➲gymnasts
➲distance runners
Adolescent Athletes
Athletes may resort to:

➲diet pills
➲diuretics
➲laxatives
➲starvation
➲enhanced sweating
Adolescent Athletes
Athletes who resort to extreme

measures to maintain weight may
be prone to disorders related to:
➲calcium
➲pyridoxine
➲iron
➲magnesium
➲zinc
Adolescent Athletes
Young athletes have greater water

requirements than do adults
Hydration during sporting events
should be monitored
Thirst is not a reliable indication of
hydration
Athletes should drink regularly
Adolescent Athletes
An estimated 7% of high school

athletes use anabolic steroids to
enhance physical performance
Iron deficiency is common among
athletes due to dietary intake and
increase loss
Section 6
On Your Own: Nutrition for
Adults
Most adults get less
exercise than when they
were teens.
Single adults tend to eat
alone and have “lazy”
eating habits.
Single adults tend to eat
out or eat too quickly and
consume unneeded
calories.
Tips for Single Adults
Invite friends over to eat; have them
bring some of the side dishes.
If eating alone, listen to music, watch a
TV program, or read while you eat. This
should help you to eat slower, since it
takes approximately 20 minutes for you
to feel full.
Prepare larger amounts and freeze
leftovers for a later meal.
Nutrition for Middle-aged
Adults
Maintain healthy
weight to avoid
problems, such as
Type-2 diabetes,
hypertension, etc.
Continue 30 minutes
of exercise daily.
May require special
diets as one ages.
Nutrition for Senior
Citizens
Consume 2 to 3
servings of calcium-
rich foods daily.
May prefer larger meal
at noon.
Eat with friends or
participate in Meals on
Wheels to receive
well-balanced meals.
The Biology of Malnutrition
– Part 4
Effects of Nutritional Insult

at Different Points in the
Lifecycle
Key Indicator of
Malnutrition
Infant Mortality Rate
 Defined as number of children per 1,000 live
births who die before their 1st birthday
US infant mortality rate: 8
 Italy 5
 Finland 4
 China 31
 India 70
 Nigeria 76
 Uganda88
Maternal Malnutrition
Studies of famine situations
 Dutch famine of WWII
 Siege of St. Petersburg
 Warsaw ghetto
Data showed effect of protein energy
malnutrition on pregnancy
 PEM early in pregnancy resulted in increased
rate of fetal loss and malformations
 PEM late in pregnancy resulted in low birth
weight babies
Effect of maternal malnutrition on
breastfeeding
 Lower volume of milk produced with
energy nutrients in the same
concentration
 Quality stays the same but quantity
diminished
 Nutrients such as calcium and iron are
taken from the maternal stores
Effect of anemia
 Increased blood volume in pregnancy results in
increased iron needs
 Maternal anemia associated with low birth
weight and then low/no stores for the infant
 Affect on infant cognition if born with low stores
 Anemia in mother also results in decreased
work capacity
 Increased maternal mortality rate
 Severe anemia accounts for up to 20% of maternal
deaths in developing countries
Affect of maternal iodine deficiency
 Cretinism in infant
Affect of maternal size
 Stunted women have smaller babies
 Smaller pelvic area also results in higher incidence
of difficult births
 Results in infant and maternal mortality
Effects of Malnutrition on
the Infant
Intra Uterine Growth Retardation
(IUGR)
 Major determinants are
 Inadequate maternal nutritional status
before conception
 Short maternal stature
 Principally due to undernutrition and infection
during childhood
 Poor maternal nutrition during pregnancy
Effects of Malnutrition on
the Infant
In industrialized countries,
cigarette smoking is the most
important determinant of IUGR
 Followed by low gestational
weight gain and low pre-
pregnancy body mass index
Effects of IUGR
IUGR newborns in industrialized countries
 Partially catch up to controls during the first 2
years of life but usually about 5 cm shorter and
5 kg lighter in adulthood
Same was shown in Guatemala, but still
shorter, lighter and weaker than controls as
young adults
Neurologic dysfunctions (ADD) and immune
function impairment also occur
Effects of IUGR
Barkers fetal origins of disease
hypothesis
 Nutritional insults during critical periods of
gestation and early infancy, followed by
relative affluence, increase the risks of
chronic diseases in adulthood
 Baby programmed for a life of scarcity and
then confronted with a world of plenty
 See increases in CVD, DM and HBP, esp. if insult is
in the 3rd trimester
Effects of IUGR
Low birthweight (<2500 gm)
results in
 a higher mortality rate
 Impaired mental function
 Majority of brain growth occurs during

fetal period and first 18 months of life
 Increased risk of adult disease
IUGR
“Intrauterine growth retardation is a
pivotal indicator of progress in breaking
the intergenerational cycle of
undernutrition, a prospective marker of a
child’s future nutrition and health status as
well as a retrospective measure of the
nutrition and health status of the mother.”
4th Report
Infant Nutritional Status
Influenced by
 Inadequate feeding
 Frequent infections
 Inadequate food
 Health
 Care
 Defined as “the behaviors and practices of caregivers
to provide the food, health care, stimulation, and
emotional support necessary for children’s health
growth and development” -4th Report
Babies who breast feed usually
have better nutritional status than
those who do not
 Infant does not compete with food
supply for family
 Breast milk is a clean food supply in a
clean container
 Breast milk has immunologic benefits so
decreases disease in this way, too
BREAST IS BEST
 Breast feeding is considered the best
method of feeding infants
Exclusive breast feeding usually
extends the time between children
 Length of the birth interval strongly
related to infant and child survival
 NOT an effective method of birth
control however
Evidence linking breastfeeding to:
 Stronger intellectual development of
the child
 Reduced risk of cancer, obesity and
several chronic diseases

 Women who were breastfed as
infants have a reduced risk of breast

cancer
Infant Feeding
Recommendations
Exclusive breast feeding for 4 to
6 months
Breastfeeding with
complementary feedings starting
at about 6 months of age
Continued breastfeeding in the
second year of life and beyond
Infant Feeding
Recommendations
Field studies show no advantage in
growth or development when
complementary foods introduced
between 4 and 6 months
 UNICEF and many ministries of health in
general recommend exclusive breastfeeding
for 6 months
 WHO recommends exclusive breast feeding
for 4-6 months, so some confusion on this
issue
Infant Feeding
Recommendations
Interventions to improve intake of
complementary foods can result in improved
infant and child growth among populations at
risk of undernutrition
 Effects of improved nutritional intake on growth are
greatest in the first year of life with significant effects
into the second and third year
 Adequate nutrition mitigates the negative effect of
diarrhea seen in these years on linear growth
Infant Feeding
Recommendations
Complementary foods are
required in the second 6 months
of life to provide adequate
nutrition and stimulate
development
 Delayed introduction of food is a
serious problem in countries such
as Bangladesh, India and Pakistan
Infant Feeding
Recommendations
Complementary foods must be
adequately dense in energy and
micronutrients to meet the
requirements of infants and young
children.
Must be prepared, stored and fed in
hygienic conditions to prevent diarrhea
Foods also must be easy to prepare and
culturally appropriate.
Breastfeeding and
HIV/AIDS
Breastfeeding is a significant and
preventable mode of HIV transmission
Observational data have shown that 3
month old infants of HIV-positive women
who were exclusively breastfed have the
same risk of contracting HIV as infants who
were never breastfed
 Partially breastfed infants had a significantly
higher risk
Breastfeeding and
HIV/AIDS
New guidelines call for urgent action to
educate, counsel, and support HIV-
positive women in making decisions
about how to feed their infants safely.
In order for a mother to make a
decision, she must have access to
 Voluntary and confidential testing and
counseling
 Information about feeding options and risk
associated with them
Breastfeeding and
HIV/AIDS
Previous recommendations stated that
infants of HIV-positive mothers in
developing countries should be
breastfed because mortality was still
lower in the breastfed infants.
Shorter duration of breastfeeding is one
option suggested in the new
UNAIDS/WHO/UNICEF guidelines
 Awaiting confirmation of protective effect of
exclusive breastfeeding
International Initiative in
Support of Optimal Infant
Feeding
3 particularly important national and

international initiatives to promote
breastfeeding
 The International Code of Marketing of
Breastmilk Substitutes – “The Code”
 The Innocenti Declaration
 The WHO/UNICEF Baby Friendly Hospital
Initiative
“The Code”
Adopted by the World Health Assembly
in 1981
Provides guidelines for the marketing of
breast milk substitutes, bottles and
teats
Aims to restrict practices that make
infant feeding decisions responsive to
market pressures
 Especially restricts direct promotion to the
public
“The Code”
Resolutions also urge
 No donations of free or subsidized
supplies of breastmilk substitutes to
any part of the health care system
Even with a mixed record of
compliance, it has had a major
impact on the way formula is
advertised and marketed
“The Code”
Has been particularly effective in
the virtual elimination of the
direct marketing to women who
receive services through the
public sector and in the
restriction of marketing to health
providers.
The Innocenti Declaration
Focuses on the need to protect,
promote, and support breastfeeding
Was signed by more than 30 countries
in 1989
One operational target of this is the
universal implementation of the Ten
Steps to Successful Breastfeeding
 Forms the basis for the WHO/UNICEF Baby
Friendly Hospital Initiative
The WHO/UNICEF Baby
Endorsed by the 45th World

Health Assembly in 1992
Has influenced the routines and
norms of hospitals around the
world through the Baby Friendly
certification process
The WHO/UNICEF Baby
A hospital is designated as Baby

Friendly when it has agreed not to
accept free or low-cost breastmilk
substitutes, feeding bottle and teats
and to implement the Ten Steps
14,500 hospitals in over 142
countries have been certified
The Maternal Milk
Protects the
baby from
 Diarrhea
 The flu
 Infection
 allergies
Mobile Restaurant
Tax free
All free
Perfectly balanced
No infections
Natural nourishment
Attractive
Open 24 hours
Service with love
in , the most nutritious,
exquisite, free food
MMM, it’s time
to eat
But what are
they going to
give me?
Ahh! My
mother chose
the best
Mother’s milk
Child
Brain cells increase in number
(hyperplasia) until about age 18
months
 Malnutrition results in fewer cells
and decreased mental capacity
 Prenatal malnutrition combined
with postnatal malnutrition leads to

a larger deficit
Child
Chronic malnutrition also has an indirect
effect on mental development because it
makes children less active and therefore
their brains are less stimulated
 Less exploratory behavior
Iodine deficiency has been shown to lower
IQ by 13.5 points
 If average is 100, -13.5 = 86.5, a level that is
only higher than about 20% of the population
Child
Measures of malnutrition
 Stunting
 Wasting
 Underweight
Child
Underweight
 Low weight-for-age at < 2SD of the median
value of the NCHS/WHO reference
 Weight for age is influenced by the height
and weight of a child
 Therefore is a composite of stunting and wasting
 Makes interpretation of this indicator difficult
since both weight for age and height for age
reflect the long-term nutrition and heath
experience of the individual or population
Child
Wasting
 < 2SD of median weight for height
 Severe < 3SD
 Usually due to acute food shortage
and/or severe disease
 Chronic dietary deficit or disease can
also lead to wasting
 This indicator is used extensively in
emergency settings
Child
Chronic low intake leads to STUNTING
 Growth charts key indicators
 Linear growth
 <2 SD from median value of international growth
reference for height = stunting
 <3 SD = severe stunting
 Poor diet and disease leads to shortness
 Know that nutrition, not heredity, is the cause
because of studies of better fed children in the
same culture and growth velocity when breastfed
Child
Incidence of stunting is estimated at
32.5% of children under age 5 in
developing countries
Potential for catch-up growth is limited
amongst stunted children after the age
of 2
 Especially kids in poor environments
Some catch-up possible between 2 and
8 /12 if NOT born with LBW or severely
stunted in infancy
Child
Stunting at age 2 is associated
significantly with later deficits in cognitive
ability
Alleviating hunger improves learning
 School feeding, both breakfast and lunch
programs, has been shown t improve school
performance in both developing and
industrialized countries
Child
Alleviating hunger helps children
perform better
 Hungry children have more difficulty
concentrating and performing complex
tasks, even if they are otherwise well
nourished
 Studies in Jamaica have shown that children
who were wasted, stunted, or previously
malnourished benefited the most from
feeding programs
Child
Poor nutrition also increases nutrition-
related illnesses, causing children to miss
more days of school
 Text cites case of 4 Latin American countries
where illness causes children to miss more
than 50 days of school a year
 This has a definite affect on learning as well
Child Catch Up
Child
A higher proportion of boys than
girls are stunted in all countries
 Probably due to the increased
time boys spend outside the home
 Girls have better physical access
to available food
Child
Ways to improve nutrition and
health status of children
 Antihelminthics
 Given in conjunction with vitamin A or iron
supplementation shows better outcomes
 Delivery of micronutrients
 Treatment of injuries and routine
health problems
Adolescents
Adolescent hormonal changes

accelerate growth
 Growth is faster than at any
other postnatal time except the
first year
Adolescent Girls
Better nourished girls
 Have higher premenarcheal growth velocity
 Reach menarche earlier
Undernourished girls
 Grow longer before a later menarche
Growth of better nourished and undernourished
girls during this period balances out
 Growth difference due to pre-existing childhood
stunting even when total growth during growth spurt
ends up being the same
Adolescent Girls
Undernourished girls grow for a longer
period of time, so may not be finished
growing before the 1st pregnancy
 Leads to smaller infants due to competition for
nutrients and poorer placental function
 Calcium a special concern since bones of
adolescents have not reached maximum density
Higher maternal and infant mortality and
pre-term delivery with adolescent
pregnancies
Adolescent Boys
Growth occurs for a longer
time before growth spurt
Velocity of growth spurt higher
and longer than for girls
Requires significant calories,
protein, iron and other
nutrients to support
Adolescents
Some catch-up growth may be possible
in adolescence but there is little
evidence to support it
“Stunted children are more likely than
non-stunted children to become
stunted adults as long as they continue
to reside in the same environment that
gave rise to the stunting”
Child  Adolescent 
Adult
Stunted women also are more likely to
have obstructed labor due to pelvic
disproportion (too small)
Stunted children lead to stunted adults,
leading to LBW infants
Smallness tends to be transmitted from
one generation to the other
Adults
“The economic livelihood of populations
depends to a large extent on the health
and nutrition of adults.” 4th Report
Adult malnutrition:
 Underweight
 Decrease in food intake, often along with disease
 Overweight
 Fewer calories out than in
 Micronutrient
Adults
Appears to be a continuous gradient
in work capacity and productivity that
is linked to body weight
 Adults with low body weight allocate
fewer days to heavy labor
 Are more likely to fail to appear for work
because of illness or exhaustion

Adults
Study of women Chinese cotton-mill
workers
 Work increased 14% for each one-gram increase
in their hemoglobin
 Increase was obtained by giving supplements
Malnutrition
 work capacity
 Income
 money for food
 malnutrition of the women and children
Adults
Mortality rates go up when BMI < 18.5
 Nigerian study showed increased mortality
rates for each level of underweight
 Mild:  40%
 Moderate:  140%
 Severe:  150%
High BMIs are also associated with
increased mortality rates
 Growing data that shows burden of obesity
is becoming greater among the poor than
others
Elderly
1950: 200 million people over

the age of 60 years
2025: projected to be 1.2
billion > 60 years
 70% will live in developing
countries
4th Report Statement
“The majority of poor older people in developing
countries enter old age after a lifetime of poverty
and deprivation, poor access to health care, and a
diet that is usually inadequate in quantity and
quality. For most of these older people,
retirement is not an option. Poverty, lack of
pensions, death of younger people from AIDS,
and rural to urban migration of younger people
are among the factors that compel older people
to continue working. Adequate nutrition, healthy
ageing, and the ability to function independently
are thus essential components of a good quality
of life.”
Elderly
Nutritional status is related to functional
ability
Undernutrition (even after controlling
for age, sex, and disease) is associated
with higher risk of impairments in
 psychomotor speed and coordination
 mobility
 the ability to carry out activities of daily
living independently
Elderly
Sarcopenia (the gradual loss of muscle
mass with age) linked to
 Age-related losses of strength
 Increased risks of morbidity
 Functional impairment
 Dependence
 Mortality
Data shows that energy and protein
intake can directly affect this condition
Elderly
Malnutrition leads to decreased
functional capacity and need for more
help
 Can contribute less to the family (i.e.
childcare)
Depression/malnutrition connection
 See downward spiral in elderly with
depression and malnutrition
 Leads to frailness and lack of ability to care
for self
Elderly
Very little experience with nutrition
interventions for older adults at the
global level
Don’t really know if nutritional status
can be improved or if it would lead to
better functional ability
Research need on adequate nutrition for
this age group
 US experience shows some possibilities
Summary
Focus should be on preventing fetal and
early childhood malnutrition, but the
life cycle dynamics of cause and
consequence demand a holistic
inclusive approach
Intervening at each point in the life
cycle will accelerate and consolidate
positive change
Alternative Food Plans: Healthy
Eating Pyramid
Alternative Food Plans:
Canada’s Food Guide
Dietary Guidelines for Americans:
ABCs for Health
Aim for fitness
 Aim for a healthy weight. If you are overweight,
first prevent further weight gain and then lose
weight gradually (1/2 to 2 pounds per week) to
improve health.
 Be physically active every day. Aim to accumulate
30 minutes (adults) or 60 minutes (children) on
most days—more if your goal is weight loss or
maintenance of weight loss.
Dietary Guidelines for
Americans: ABCs for Health
Build a healthy base

 Let the Pyramid guide your food choices.
 Eat a variety of grains daily, especially whole
grains.
 Eat a variety of fruits and vegetables daily.
Favor dark-green leafy vegetables, bright
orange fruits and vegetables, and cooked
dried peas and beans.
 Keep food safe to eat.
Choose sensibly
 Choose a diet low in saturated fat and
cholesterol and moderate in total fat.
Focus on keeping intake of saturated and
trans fats as low as possible.
 Choose beverages and foods to moderate
your intake of sugars. Limit your
consumption of regular soda, candies,
sweet desserts, and fruit drinks.
Choose sensibly (continued)

 Choose and prepare foods with less salt.
 DRI for sodium = 1500 mg/day (about 2/3 teaspoon of salt)
 UL for sodium = 2300 mg/day
 The majority of Americans exceed the UL.
 If you drink alcoholic beverages, do so in
moderation
 No more than 2 drinks/day for men
 No more than 1 drink/day for women
Dietary Challenges for Special
Population Groups: Athletes
Energy intake—adequate calories and
nutrients
Carbohydrates—60 to 65% of total daily
calories for most athletes, up to 70% for
endurance athletes
Protein (grams per day per kilogram of body
weight)
 Endurance athletes: 1.2 to 1.4 grams
 Heavy strength training: 1.6 to 1.7 grams
Fluids—remain hydrated
 14 to 22 oz of fluid two hours before strenuous
event
 6 to 12 oz every 15–20 minutes during exercise
 Replace fluids after event (check body weight)
Calories Needed Daily
Activity Minutes Kcals Body wt Cals burned
Sleep 480 .008 130 499

Class 350 .011 130 500
Walking 40 .020 130 104
Eating 90 .011 130 128
Practice-Light 40 .050 130 260
Practice-Hard 80 .090 130 936
Standing 60 .012 130 94
Studying 180 .012 130 281
TV/computer/phon 120 .012 130 187
2,989 Calories
burned in 24 hours
Foods High in Starch:
Pastas Dried peas

Macaroni Split peas
Spaghetti Lentils
Noodles Black-Eyed peas
Ravioli Starchy Vegetables
Dried beans Potatoes
Lima beans Carrots
Navy beans Peas
Kidney beans Corn
Rice Winter squash
Brown rice Sweet potatoes
Wild rice Cereals
White rice Hot cereals (like oatmeal)
polished or unpolished Cold cereals (like wheat
Breads flakes)
Rolls & Muffins Avoid highly sugared cereals
Crackers
Sliced breads
Pancakes
Make sure your pre-game meal plans follow these guidelines:
•Allow enough time for digestion. Eat the meal at least three hours
before an event.
•Choose a meal that's high in starch. Starch is easy to digest and
helps steady the levels of blood sugar.
•Consume only moderate amounts of protein. Protein foods take
longer to digest than starch. And high-protein meals may lead to
increased urine production, which can add to dehydration.
•Limit fats and oils. They take too long to digest.
•Restrict sugary foods. Sweets can cause rapid energy swings in
blood sugar levels and result in low blood sugar and less energy.
•Avoid foods and drinks that contain caffeine. Caffeine stimulates
the body to increase urine output, which can contribute to
dehydration problems, and a full bladder can be very uncomfortable.
•Watch out for foods that produce gas. Certain raw vegetables,
fruits, or beans may cause problems for some young athletes. Be
aware of the foods that cause you problems, and avoid them just
before an event.
•Within these guidelines, chose foods you like to eat.
•Remember to drink plenty of fluids with your pre-game meal.
Top 10 Fruits & Vegetables
According to Cornell University, diets rich in antioxidants (veggies are
full of them) are linked to improved lung function and may prevent
respiratory diseases such as asthma, emphysema and chronic
bronchitis.
Broccoli
Cabbage
Cantaloupe
Carrots
Kale
Mangoes
Pumpkin
Red bell pepper
Spinach
Sweet potato
* Strawberries make the list if purchased organically.
Calcium Absorption
No caffeine – caffeine increases the
excretion of calcium in urine.
Avoid too much protein – too high of levels
seems to leech calcium from the bones –
animal protein seems to have a worse
effect than plant protein.
Avoid high levels of sugar – sugar blocks
the absorption of calcium…be careful of
skim milk – it has more sugar than 1 & 2%.
Avoid a diet high in sodium – people with
diets high in sodium seem to have a much
higher incidence of osteoporosis.
Good Sources of
Calcium
Yogurt
Greens – collard greens, spinich
Milk
Cheese
Cottage Cheese
Beans & Peas (Blackeye especially)
Salmon & Sardines
Nuts
How to do it…
Variety: try to have a variety of colors and foods – grains,
veggies, meat or protein rich food.
Prepare smaller, more frequent meals. Ideally 4-5 meals.
Snack on fruits, veggies, & nuts during the day.
Drink at least ½ your body weight in water.
Don’t drink soda or coffee.
Try to have a diet low in sodium and sugar
Keep it natural – steer away from processed food when you
can and buy organic whenever possible.
When cooking, use extra virgin olive oil, stay away from
margarine, again natural is better.
Further reading…
Sally Fallon, Nourishing Traditions
Dean Ornish, MD has several books.
Michael Colgan, MD – Optimum Sports
Nutrition
Calcium info -
http://www.hsph.harvard.edu/nutritionsource/ca
How to buy cheap organic food -
http://www.bankrate.com/brm/news/cheap/2004
And remember…
Stay Away From

Fast Food…
(if you need some
encouragement watch the
movie Supersize Me)

Nutrition During The Life Cycle

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Nutrition During the Life

Life Cycle: The various stages of

Describe how these factors

Read, come to class, read

HB 13.0 12.2 10.9 11.0 12.4

Serum 90.0 106.5 75.3 56.0 57.1

Prepregnancy BMI Weight Gain

Teens should strive for weight gain at upper end of ranges to

Increased energy needs (+200 Kcals)

Food choices for pregnant women

 Perinatal mortality rate not affected

 No increase incidence of malformation

 In healthy women, state of near starvation is needed to

affect pregnancy outcome

early newborn deaths

age, preterm birth

Cunningham et al 1997; Susser and Stein 1994.

 Inconclusive results to demonstrate or exclude effect

on fetal growth or any significant effect on other

 Balanced protein and energy: minimal increase in

average birth weight (~30 g) and small decrease in

from a balanced energy/protein supplementation

Enkin et al 2000; de Onis, Villar and Gülmezoglu 1998.

Increase in maternal tissue (breast

Increase in fetal tissues

Metabolic “cost” of pregnancy = tissue

Maternal anabolic phase: 0-20 weeks

Energy utilization during pregnancy:

 Maternal gain breast tissue, uterine muscles and placenta

Result: BMR ↑ 60% 2nd and 3rd trimesters (catabolic

3 possible adaptive responses:

Usually all 3, but varies from woman to

HCG (human chorionic gonadotrophin)

Needs must be met by maternal intake or

Changes directed toward maintaining availability

Early pregnancy (12-14 weeks) – enhanced early

End result: increased glucose availability

0.7------- ↑ --------.82-------- ↑ --------->1.0----->1.0+

 What would the RQ of a pregnant woman be?

RQ in late pregnancy higher than post-

Probably due to fetal utilization of

Do pregnant women need to increase

Do pregnant women need to change

Need for 80,000 kcal positive balance

Consider in terms of energy balance

Need to consider all sources of energy

Many ways to achieve positive energy balance

Which occur depend on fetal needs,

Underweight women, fixed dietary intake,

 Only possible changes are enhanced metabolic

 May permit continuation of pregnancy, but

 Pre-existing fat stores, increased dietary

 Greater increase in BMR (about 20%) ? to

Normal weight women:

 Variable increase in dietary intake

Second trimester: additional 340 kcal/day

Appropriate intakes monitored by weight

Weight gain recommendations vary with

Optimal weight gain dependent on pre-

 First trimester 3-5 lb total

 Normal & underweight 0.5 lb/week 2nd trimester

 Overweight 0.5 lb/week 3rd trimester