1. Chapter 13 Nutrition for a Life time

2. Energy Needs During Pregnancy 1st trimester – Balanced and adequate diet 2nd and 3rd trimester – 350-450 extra kcal per day 3 rd trimester Transfer of fat, calcium, and iron to fetus during the last month Fetus may deplete mother’s store of iron if intake is low Choose nutrient dense foods Physical Activity – Increase kcalories if exercising 2

3. 3 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  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.

4. 4 Iron Supplementation Iron requirements: Average non-pregnant adult: –800  g iron lost/day –+ 500  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  g folic acid Mahomed 2000b; WHO 1994.

5. 5 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.

6. 6 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.

7. 7 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.

8. 8 Calcium Supplementation: 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 Atallah, Hofmeyr and Duley 2000.

9. Recommended weight grain during pregnancy 2 - 4 lb. weight gain during 1st trimester 0.75 - 1 lb. weekly weight gain during 2nd and 3rd trimester Total weight gain goal – 25 - 35 lb. for normal weight women – 28 - 40 lb. for low weight (BMI < 19.8) – 15 - 25 for high weight (BMI 26-29) – 15 - 25 lb. for obese (BMI > 29) 9

10. Components of Weight Gain 10Nutrition and Micronutrients in Pregnancy

11. Protein and Carbohydrate need during pregnancy RDA for protein – Additional 25 gm/day – Many (non-pregnant) women already consume recommended amount of protein RDA for carbohydrate – Prevent ketosis – 175 gm/day – Most women exceed this amount 11

12. Additional Mineral Need Calcium (1000 mg/day) – Adequate mineralization of fetal skeleton and teeth Iron (27 mg/day) Increased hemoglobin Iron stores for the fetus Iron supplement between meals Possible effects of iron-deficiency anemia – Preterm delivery – Low-birth weight – Fetal deaths Zinc (11 mg/day) supports growth and development 12

13. Pregnant vs. Nonpregnanat 13 Energy/NutrientNon-pregnantPregnant Protein46 g/day71 g/day Vitamin C75 mg/day85 mg/day Thiamin1.1 mg/day1.4 mg/day Niacin14 mg/day18 mg/day Folate400 mcg/day600 mg/day Vitamin D5 mcg/day Calcium1000 mg/day Iron18 mg/day27 mg/day Iodine150 mcg/day220 mcg/day

14. What about Aspartame Harmful for mothers with phenylketonuria (PKU) – Disrupts fetal brain development Moderate use not harmful for women who do not have PKU 14 What about Caffeine Decreases iron absorption May reduce blood flow through the placenta Caffeine withdrawal symptoms in newborn Risk of spontaneous abortion – Heavy caffeine use in the 1st trimester Risk of low-birth-weight infant Limit caffeine intake (< 3 cups coffee/day)

15. Pregnancy Complications Gestational Diabetes – Hormones synthesized by placenta decrease action of insulin – 4% of pregnancies; 7% of Caucasian women – Routine screening at 20 - 28 weeks gestation Risks to fetus & mother – Increased birth weight (C-section), low blood glucose, trauma, malformations – Usually disappears after birth but is linked to diabetes later in life for mother 15

16. Pregnancy Complications Pregnancy-induced hypertension – High-risk disorder Preeclampsia (mild form) – Eclampsia (severe form) Signs: – Elevated blood pressure, protein in the urine, edema, change in blood clotting – Convulsions in third trimester – Liver and kidney damage, leading to death 16

17. Nutrition in Infants Nutrition in Infancy  Water: 100-150ml/kg/day  Protein: 2-3gm/kg/day  Lipids: 3.8-6.0 gm/kg/day (MCT and EFA)  Carbohydrate:40%-50% of total calories  Calcium: 400-600mg/day  Iron: 6-10mg/day  Fluoride, vitamin D, vitamin K 17

18. Recommendations for Infants  The WHO recommends human milk as the exclusive nutrient source for feeding full-term infants during the first 6 months after birth  Regardless of when complementary foods are introduced, breastfeeding should be continued through the first 12 months 18

19. Breast Milk Content  Human milk contains protective antibodies against enteric infections  Caloric density is the same in breast milk and regular infant formulas(20kcal/oz)  Fat absorption is more efficient in breastfed infants when compare to infant formulas 19

20. Breast Milk/Formula Content  Human milk has higher concentration of essential fatty acid  Formula has higher protein concentration (1.5g/dl in formula vs.0.9g/dl in breast milk) whey/casein in human milk- 80:20 whey/casein in formula-18:82  Whey protein promotes gastric emptying  Whey protein have more lactoferrin and secretory immunoglobulin A  Lactose content is equal in breast milk and infant formula  Calcium/Phosphorus ratio in human milk is higher compared to formula (2:1 vs. 1.5:1)  Human milk has lower iron concentration but iron from human milk is more bio-available 20

21. Infection and Breast Milk  Human milk may be a source of CMV  Human milk is protective against enteropathogenic E.coli and other GI pathogens. This protection is greatest during the infant’s first 3 months of life and declines with increasing age  Human milk is not protective against HSV  Breastfeeding is contraindicated in HIV infection, except in underdeveloped countries  Human milk does not protect against M.tuberculosis 21

22. Infant Benefits of Breastfeeding  Protein in breast milk is more easily digested that protein in infant’s formula  Human milk protein promotes more rapid gastric emptying  Fat absorption from human milk is more efficient when compared to formula  Many factors in human milk may stimulate gastrointestinal growth and motility as well as enhance the maturity of the gastrointestinal track  Human milk contains specific protein involved in host defense Infants who are breastfed for at least 13 weeks had significantly less gastrointestinal and respiratory illnesses  Breast milk appears to be protective against some food allergies during infancy and early childhood  Maternal-infant bonding is enhanced during breastfeeding  Improved long-term cognitive and motor abilities in full term infants have been directly correlated with duration of breastfeeding 22

23. Breast Milk vs. Cow’s Milk vs. Iron- Fortified Formulas ProductEnerg y (Cal/o z) Protein (g/oz) Carbs (g/oz) Fat (g/oz) Cholest erol (mg/oz) Iron (mg/oz) Calcium (mg/oz) Human milk 22.50.322.12.1.354.000.0110.0 Cow’s milk, whole 20.11.081.601,083.000.0134.0 Cow’s milk, fat- free 10.81.081.560.031.000.0138.0 Similac20.00.412.101.081.000.3616.0 Enfamil20.00.422.191.070.00.0.3616.0 ProSobee200.502.131.070.000.3621.0 Isomil200.492.041.090.000.3621.0

24. Mother Benefits  Postpartum weight loss and uterine involution may be more rapid in women who breastfeed  Exclusive breastfeeding delays the resumption of normal ovarian cycles and return of fertility in most mothers  Epidemiological studies have identified a decreased incidence of premenopausal breast cancer and ovarian cancer in women who have lactated 24

25. Infant and Nutrition 25Nutrition and Micronutrients in Pregnancy

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27. Dietary Fat  No fat restriction for children less than 2y  Nonfat and low-fat milk not recommended in the 1st 2 years of life  Fat intake should be decreased during toddlers years, to provide 30% of total energy  Lower limit of energy from fat should be 20% 27

28. Baby Bottle Caries 28

29. What not to Feed an Infant 29

30. Dietary Guidelines in Childhood  Structured 3 meals and 2 snacks  Adults should decide when food is offered  Eating should occur in a designated area with the developmentally appropriate chair  No grazing between meals  For preschoolers offer 1 tablespoon of each food for every year of age  Snacks should be considered mini-meals 30

31. Children: Daily food Plan Energy/Food Groups2-3 years4-5 years Calories10001200 Grains3 oz4 oz Vegetables1 cup1.5 cups Fruits1 cup Milk2 cups Meat2 oz Oils 3tsp4 tsp 31

32. School-age Children: Daily Food Plan Food Group Age 6- 7, Girls Age 6- 7, Boys Age 8 Both Age 9- 10. Girls Age 9-10, Boys Age 11- 12, Girls Age 11-12, Boys Calorie s 12001400 1600 1800 Grains3 oz4 oz 5 oz 6 oz Veg1.5 cups 2 cups 2.5 cups Fruit1 cup1.5 cups Milk2 cups 3 cups Meat3 oz4 oz 5 oz Oil4 tsp 5 tsp 32

33. Adolescent Nutrition  Recommended daily allowances (RDA) for energy based on the median energy intake  Assessment of energy needs should consider appetite, growth, activity and weight gain in relation to deposition of subcutaneous fat  Restricted food intake in physically active adolescents results in diminished growth, drop in basal metabolic rate and amenorrhea  Requirements for energy, calcium, nitrogen and iron determined by increases in Lean Body Mass 33

34. Nutritional Concerns in Adolescence  The low energy intake creates difficulties in planning diets with adequate levels of nutrients  RDA for energy do not include a safety factor for increased energy needs (illness)  Protein needs correlate more with growth pattern than with chronological age  Due to accelerated muscular and skeletal growth, calcium need is higher  Need for iron is increased to sustain the rapidly enlarging LBM and hemoglobin mass  Iron needed to offset menstrual losses  Zinc is essential for growth and sexual maturation  Growth retardation and hypogonadism have been reported in adolescent boys with Zinc deficiency 34

35. Nutrition Concerns in Adolescents  Vegetarian adolescents at risk for deficiencies of vitamin D, B 12, riboflavin, protein, calcium, iron, zinc and trace elements  Dental caries are common (low fluoride intake, high carbohydrate intake)  NHANES reports obesity in 14% of adolescent ages 12-19  Chronic disease in adolescent may affect nutritional status 35

36. Adolescents: Daily Food Plan Energy/ Food Group 13 yo, Girls 14-18 yo, Girls 19-20 yo, Girls 13-15 yo, Boys 16-18 yo, boys 19-20 yo boys Calories160018002000 24002600 Grains5 oz6 oz 8 oz9 oz Veg2 cups2.5 cups 3 cups3.5 cups Fruits 1.5 cups 2 cups Milks3 cups Meat5 oz 5.5 oz 6.5 oz Oils5 tsp 6 tap 7 tap 36

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40. The Elderly Currently Underutilize Resources To Combat Malnutrition 22% Use Community Services 15% Use Senior Centers 8% Eat Meals at Senior Centers 2% Receive Home Delivered Meals 40

41. Poorly Nourished Older Adults Greater morbidity/mortality Declining functional status Greater rates of hospital admission/readmission (ALOS +2days; 4x hospitalization rate) Higher rate of complications (Tenfold increase in nosocomial infection rate) 41Nutrition and Micronutrients in Pregnancy

42. As we age Body Composition Total Body Fat Muscle Mass Total body water Bone Mass (with ↑ potential of fracture) Dentition 42 Body Functions > dry mouth < taste / smell < thirst (with ↑ potential of dehydration) ↑ anorexia with ↓ appetite ↓ T cell and B cell activity < GFR < activity of drug metabolizing enzymes < availability of nutrients via absorption / digestion

43. Food Pyramid for Older Adults Key Considerations More water/fluids on a daily basis Fewer calories/Encourage physical activity More fiber Consider supplements: –calcium, vitamin D and B12 43

44. Older Adults (70+): Daily Food Plan Energy/Food groupFemalesMales Calories16002000 Grains5 oz6 oz Veg2 cups2.5 cups Fruits1.5 cups2 cups Milk3 cups Meat5 oz5.5 oz Oil5 tsp6 tsp 44

45. Conclusions for the class 45 Eating habits are learned Eating is ….. Nutrition is …… Exercise is ……