1. NUTRITION IN CHILDHOOD & ADOLESCENCE DR RAB NAWAZ MBBS, MPH, PGD (Nutrition), Bannu Medical College Bannu, NWFP, PAKISTAN

2. Food Guide Pyramid The Food Pyramid, developed by the US Department of Agriculture (USDA), is an excellent tool to help you make healthy food choices. The food pyramid can help you choose from a variety of foods so you get the nutrients you need, and the suggested serving sizes can help you control the amount of calories, fat, saturated fat, cholesterol, sugar or sodium in your diet. Grains, Bread, Cereal and Pasta form the Base Grains, Bread, Cereal and Pasta form the Base Fruits and Vegetables Fruits and Vegetables Lean Meat and Fish, Beans, Eggs Lean Meat and Fish, Beans, Eggs Dairy Products Dairy Products Fats and Sweets Fats and Sweets

3. Food Guide Pyramid (2) What counts as ONE serving Grain group: 1 slice of bread, ½ cup of cooked rice, ½ cup of cooked cereals, 1 ounce of ready to eat cereal. Grain group: 1 slice of bread, ½ cup of cooked rice, ½ cup of cooked cereals, 1 ounce of ready to eat cereal. Fruit/ Vegetable group: ½ cup of chopped raw or cooked vegetables, ½ cup of raw leafy vegetable, 1 Fruit/ Vegetable group: ½ cup of chopped raw or cooked vegetables, ½ cup of raw leafy vegetable, 1 piece of fruit or one melon wedge, ¾ cup of juice, ½ cup of canned fruit, ¼ cup of dried fruit Meat group: 2-3 ounce of cooked lean meat, poultry or fish, ½ cup of cooked dried beans or 1 egg (counts 1 ounce of lean meat), 2 tablespoon of peanut butter (counts 1 ounce of lean meat) Meat group: 2-3 ounce of cooked lean meat, poultry or fish, ½ cup of cooked dried beans or 1 egg (counts 1 ounce of lean meat), 2 tablespoon of peanut butter (counts 1 ounce of lean meat) Milk group: 1 cup of milk or yogurt, 2 ounces of cheese Milk group: 1 cup of milk or yogurt, 2 ounces of cheese Fats & Sweets group: limit calories from these. Fats & Sweets group: limit calories from these. 4-6 years old children can eat these serving sizes. For children below 4 years, a total of 2 servings from the milk group each day.

5. CHILDHOOD From age 1 through the beginning of adolescence. From age 1 through the beginning of adolescence. Growth in childhood slower than infancy. Growth in childhood slower than infancy. Weight gain about 5 pounds and grow 2-3 inches annually. Weight gain about 5 pounds and grow 2-3 inches annually. Three groups on the basis of age and development Three groups on the basis of age and development Toddlers (Age 1-3 years) Toddlers (Age 1-3 years) Preschoolers (Age 4-5 years) Preschoolers (Age 4-5 years) School children (Age 6-10 years) School children (Age 6-10 years) Energy & Proteins RDAs for children Age (y) Kcal/kg Kcal/day Proteins g/kg Proteins g/day Age (y) Kcal/kg Kcal/day Proteins g/kg Proteins g/day 1-3 10213001.2 16 1-3 10213001.2 16 4-6 9018001.1 24 4-6 9018001.1 24 7-10 7020001.0 28 7-10 7020001.0 28 On average 1 year old child requires 1000-1300 Kcal/day. This energy requirement doubles by 10 years age.

6. Vitamins and minerals With cooperation of healthy child a well planned diet provide most nutrients except iron. With cooperation of healthy child a well planned diet provide most nutrients except iron. RDA for iron during childhood (1-3 years) is 7 mg. RDA for iron during childhood (1-3 years) is 7 mg. RDA for iron during childhood (4-8 years) is 10 mg. RDA for iron during childhood (4-8 years) is 10 mg. As iron is low source of iron, so much consumption of milk contribute to low iron intake. Milk should be limited to 3-4 cups which allows room for diet rich in iron like lean meats, legumes, fish, poultry and cereals etc. As iron is low source of iron, so much consumption of milk contribute to low iron intake. Milk should be limited to 3-4 cups which allows room for diet rich in iron like lean meats, legumes, fish, poultry and cereals etc. A child diet may also be deficient in other micronutrients like zinc, vitamin D & E. Those children who are on low fat diets i.e. low fat dairy products suffer more. A child diet may also be deficient in other micronutrients like zinc, vitamin D & E. Those children who are on low fat diets i.e. low fat dairy products suffer more. Outside influences such as TV viewing, affect children preferences for low nutrient density foods. Outside influences such as TV viewing, affect children preferences for low nutrient density foods. Nutritional concerns of childhood Hunger Hunger Malnutrition, Micronutrients and PEM. Malnutrition, Micronutrients and PEM. Deficiencies of vitamins A, D, Zinc, Iron and proteins. Deficiencies of vitamins A, D, Zinc, Iron and proteins. These result in illnesses, stunted growth, limited development and in case of vitamin A deficiency possibly permanent blindness. These result in illnesses, stunted growth, limited development and in case of vitamin A deficiency possibly permanent blindness.

7. ADOLESCENCE It is the time between the onset of puberty and adulthood. It is the time between the onset of puberty and adulthood. Boys grow about 8 inches, gain about 45 pounds and increase their lean body mass. Boys grow about 8 inches, gain about 45 pounds and increase their lean body mass. Girls grow about 6 inches, gain about 35 pounds and increase their body fat. Girls grow about 6 inches, gain about 35 pounds and increase their body fat. Growth through adolescence is hormone driven. Growth spurts for girls begin Growth through adolescence is hormone driven. Growth spurts for girls begin between ages 10.5 and 11 years with a peak in the rate of growth at around age 12. For boys growth spurts usually begin between ages 12.5 and 13 and peak at around age 14. This period of maximal growth lasts about 2 years. Adolescence is an uncomfortable time for the teen who is concerned with body image Adolescence is an uncomfortable time for the teen who is concerned with body image or body changes or athletic activities. Low nutrient snacks are a large part of the diet and adequate amounts of fruits and Low nutrient snacks are a large part of the diet and adequate amounts of fruits and vegetables are missing. Factors that determine food selection and consumption include the desire to be Factors that determine food selection and consumption include the desire to be healthy, fitness goals, amount of discretionary income, social practices and peers.

8. Nutrient needs of adolescents Growth not age should be ultimate indicator of nutrient needs. Growth not age should be ultimate indicator of nutrient needs. Energy needs are greater during adolescence than at any other time of life with exception of pregnancy & lactation. Energy needs are greater during adolescence than at any other time of life with exception of pregnancy & lactation. Energy & Proteins RDAs Energy & Proteins RDAsMales Age (yrs) Kcal/kg Kcal/day Proteins g/kg Proteins gm/day 11-14 55 2500 1.0 45 15-18 45 3000 0.9 59 Females Age (yrs) Kcal/kg Kcal/day Proteins g/kg Proteins gm/day 11-14 47 2200 1.0 46 15-18 40 2200 0.9 44 Vitamins & Minerals Vitamins & Minerals Higher vitamins and minerals needs. Higher vitamins and minerals needs. Three nutrients of importance i.e. vitamin A, iron and calcium. Three nutrients of importance i.e. vitamin A, iron and calcium. AI for calcium 1300 mg/day, for iron is 11 mg/day (boys) and 15 mg/day (girls). AI for calcium 1300 mg/day, for iron is 11 mg/day (boys) and 15 mg/day (girls). Improving fruit & vegetable intake will help in obtaining adequate vitamin A. Improving fruit & vegetable intake will help in obtaining adequate vitamin A.

9. PREGNANCY Time of tremendous changes, guided by changing levels of hormones. Uterine, breast and adipose tissues grow, blood volume expands and gastrointestinal motility slows. All these changes have nutritional and dietary implications for pregnant women. Time of tremendous changes, guided by changing levels of hormones. Uterine, breast and adipose tissues grow, blood volume expands and gastrointestinal motility slows. All these changes have nutritional and dietary implications for pregnant women. Weight gained during pregnancy is a combination of fetal and maternal tissues and fluids. Weight gain recommendations are based on BMI prior to pregnancy. Women of normal weight (BMI=19.8-26) should gain 25-35 pounds over the course of pregnancy Most of this weight gain occurs during the second & third trimester. Weight gained during pregnancy is a combination of fetal and maternal tissues and fluids. Weight gain recommendations are based on BMI prior to pregnancy. Women of normal weight (BMI=19.8-26) should gain 25-35 pounds over the course of pregnancy Most of this weight gain occurs during the second & third trimester. Nutrition related components of preconception care Risk assessment: Age, Diet, Substance use, existing medical condition, Barriers to prenatal care and PHC. Risk assessment: Age, Diet, Substance use, existing medical condition, Barriers to prenatal care and PHC. Health Promotion: Healthful diet and refraining from substance use. Compliance with prenatal care. Health Promotion: Healthful diet and refraining from substance use. Compliance with prenatal care. Interventions: Referral to hospitals with highly equipped and trained staff. Nutrition counseling, supplementation or referral to improve diet as needed. Interventions: Referral to hospitals with highly equipped and trained staff. Nutrition counseling, supplementation or referral to improve diet as needed. Nutrient needs of Pregnancy A pregnant woman requires added calories to grow and maintain not just her developing fetus but also the placenta, increased breast tissue and fat stores. A pregnant woman requires added calories to grow and maintain not just her developing fetus but also the placenta, increased breast tissue and fat stores. Growth & development of the fetus also requires nutrients—carbohydrates, and fat as a source of energy while proteins, vitamins and minerals to support growth and cell differentiation. Growth & development of the fetus also requires nutrients—carbohydrates, and fat as a source of energy while proteins, vitamins and minerals to support growth and cell differentiation.

10. Nutritional Recommendations for Pregnancy Non-pregnantPregnant % Increase Energy (Kcal)2200250014 Proteins466030 Vit A (ug)70077010 Vit D (ug)550 Vit E (mg)15150 Vit (K (ug)90900 Thiamine (mg)1.11.427 Riboflavin (mg)1.11.427 Niacin (mg)141829 Vit B6 1.31.946 Folate (ug)40060050 Vit B12 (ug)2.42.68 Choline (mg)4254506 Vit C (mg)758513 Calcium (mg)100010000 Phosphorus (mg)7007000 Magnesium (mg)31035013 Iron (mg)182750 Zinc (mg)81138 Iodine (ug)15022047 Copper (ug)900100011

11. Folic acid supplementation before pregnancy reduces the risk of neural tube defects such as spina bifida. Folic acid supplementation before pregnancy reduces the risk of neural tube defects such as spina bifida. Excessive intake of some vitamins (A) and use of drugs increase the risk of poor pregnancy outcome. Excessive intake of some vitamins (A) and use of drugs increase the risk of poor pregnancy outcome. The energy RDA increases by 300 Kcal/day for the 2 nd & 3 rd trimesters. The energy RDA increases by 300 Kcal/day for the 2 nd & 3 rd trimesters. Protein needs increases by about 10 gm/day while CHO & fats as for non pregnant women. Protein needs increases by about 10 gm/day while CHO & fats as for non pregnant women. The diet should contain CHO & fats in the same proportion as recommended for non pregnant women. The diet should contain CHO & fats in the same proportion as recommended for non pregnant women. Using the FGP pregnant women who consume enough energy should be able to meet all their nutrients needs except iron & folate. They should get extra calories mainly from grains, fruits and vegetables. Using the FGP pregnant women who consume enough energy should be able to meet all their nutrients needs except iron & folate. They should get extra calories mainly from grains, fruits and vegetables.

12. LACTATION Breast feeding mother must choose a varied, healthful and nutrient dense diet. Breast feeding mother must choose a varied, healthful and nutrient dense diet. Need for energy and many nutrients is higher during lactation than during pregnancy. Need for energy and many nutrients is higher during lactation than during pregnancy. RDA values suggest an additional 500 Kcal and 12-15 grams of proteins each day. RDA values suggest an additional 500 Kcal and 12-15 grams of proteins each day. RI levels for minerals are generally higher during lactation than during pregnancy. RI levels for minerals are generally higher during lactation than during pregnancy. Fluids are also important for adequate milk production. Fluids are also important for adequate milk production. Food choices during lactation should follow the USDA Food Guide Pyramid and emphasize nutrient dense foods. Food choices during lactation should follow the USDA Food Guide Pyramid and emphasize nutrient dense foods. With good choices and adequate intake a lactating mother may not need vitamin or mineral supplementations. With good choices and adequate intake a lactating mother may not need vitamin or mineral supplementations. The main CHO in breast milk is lactose while triglycerides are the main source of energy in breast milk. The main CHO in breast milk is lactose while triglycerides are the main source of energy in breast milk. Benefits of Breastfeeding For infants For infants For mothers For mothers For country For country Advantages of human milk over cows milk Proteins: more whey less casein, less phenylalanine, more peptidases Lipids:more lipase enzymes, more Linoleic acid, higher polyunsaturated to saturated fatty acid ratio, more cholesterol. Minerals:Less calcium, less sodium, higher calcium to phosphorus ratio, iron and zinc in more available form

13. Unless the lactating mother reduce their physical activity, breastfeeding women need about 500 more Kcal/day than they did when they were not pregnant. Obtaining adequate energy and using the Food Guide Pyramid to balance choices most lactating women can obtain all the nutrients they need from their diet. Alcohol, cigarettes and drugs should not be used while breast feeding. Unless the lactating mother reduce their physical activity, breastfeeding women need about 500 more Kcal/day than they did when they were not pregnant. Obtaining adequate energy and using the Food Guide Pyramid to balance choices most lactating women can obtain all the nutrients they need from their diet. Alcohol, cigarettes and drugs should not be used while breast feeding. Nursing mothers should eat plenty of vegetables (source of many micronutrients) Nursing mothers should eat plenty of vegetables (source of many micronutrients) Vegetables of cabbage family causes colic symptoms in breastfed children. Other foods with bad reputation include peanut butter, chocolate, egg whites and nuts. But removal of these foods from the diet should be done only under the supervision of a registered dietitian. Vegetables of cabbage family causes colic symptoms in breastfed children. Other foods with bad reputation include peanut butter, chocolate, egg whites and nuts. But removal of these foods from the diet should be done only under the supervision of a registered dietitian. Vegan women and who do not follow diet guidelines, should take vitamin B12 supplement. Vegan women and who do not follow diet guidelines, should take vitamin B12 supplement. Those women who do not get regular sun exposure or do not drink milk or other fortified foods should get vitamin D supplementation. Those women who do not get regular sun exposure or do not drink milk or other fortified foods should get vitamin D supplementation. For most nursing mothers dietary counseling is the preferred way to address nutrient imbalances. For most nursing mothers dietary counseling is the preferred way to address nutrient imbalances.