Chapter 13 Nutrition for a Life time

1. Chapter 13Nutrition 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 • 3rd 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

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. 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. 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. 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. 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. 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)

10. Components of Weight Gain Nutrition 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

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

13. Pregnant vs. Nonpregnanat

14. What about Aspartame 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) Harmful for mothers with phenylketonuria (PKU) – Disrupts fetal brain development • Moderate use not harmful for women who do not have PKU

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

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

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

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

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

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

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

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

23. Breast Milk vs. Cow’s Milk vs. Iron-Fortified Formulas

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

25. Infant and Nutrition Nutrition and Micronutrients in Pregnancy

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%

28. Baby Bottle Caries

29. What not to Feed an Infant

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

31. Children: Daily food Plan

32. School-age Children: Daily Food Plan

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

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

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

36. Adolescents: Daily Food Plan

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

41. Poorly Nourished Older Adults Nutrition and Micronutrients in Pregnancy 􀁻 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)

42. As we age 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 Body Composition Total Body Fat Muscle Mass Total body water Bone Mass (with ↑ potential of fracture) Dentition

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

44. Older Adults (70+): Daily Food Plan

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