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Nutrition Across the Life Span Child • Infant Elderly • Growth Development • Prevent disease • Promote health • Role of Nutrition Adolescence Prolong life Pregnancy Adult Nutrition in Pregnancy Stages of Pregnancy & Birth Terms for Stages surrounding Pregnancy and Birth Fertilization Birth GESTATION Preterm 0 2 8 20 37 38 28 Postte rm Term 40 42 44 Postnatal or postpartum Prenatal or Antenatal Perinatal Zygote Embryo Preconception = before pregnancy Fetus Periconception = 1→3 months before pregnancy to the first 6 weeks after delivery Infant Neonate Physiological Changes during Pregnancy • Endocrine • Body composition • Blood volume & composition • Metabolism • Cardiovascular • Respiration • Kidney • Gastrointestinal Nutritional Requirements in Pregnancy There is increased need for energy and nutrients to support growth of the fetus, placenta and maternal tissue. Physiologic changes that cause hemodilution causes changes in nutrient turnover and homeostasis that affects requirements. Fetal demands occurs primarily during the second half of pregnancy when more than 90% of growth occurs. Energy Needs China RNI Energy (Nonpregnant) Light Moderate Heavy Energy (Pregnant) Full activity Reduced Women 18-55 2100 2100 2350 +285 Women <55 2050 2150 2350 +200 • 1st trimester additional energy requirement is small • 2nd / 3rd trimester + 200 - 300 kcal/day • Pregnant teenagers, underweight women, physically active women need more • Increased energy due to 25% increase in basal energy requirements (growth of fetus, accessory tissues, maternal supporting tissues) and increased requirement by mother due to her increased weight Energy & Related Nutrient Needs Singapore RDDA B1 thiamin, mg B2 riboflavin, mg B3 niacin, mg Women 18-30 0.84 1.26 13.9 Women 30-60 0.86 1.29 14.2 Pregnant –full activity +0.11 +0.17 +1.9 Pregnant –reduced +0.08 +0.12 +1.3 • as energy requirement increases the need for thiamin, niacin & riboflavin increase proportionally • they are coenzymes in reactions that releases energy from CHO, protein and fat Macronutrient Needs Singapore RDDA Women 18-30 Women 30-60 Pregnant –full activity Protein, g 58 58 +9 CHO, g 275 282 +39 Fat, g 56 57 +8 Pregnant –reduced +9 +28 +6 • Protein essential for: – synthesis of fetal & placental protein – increased maternal protein synthesis to support expansion of blood volume & growth of breasts & uterus • Vitamin B6 (pyridoxine) required for protein synthesis, therefore increase requirement during pregnancy • CHO & fats help make up calories, spare protein Critical Periods Vulnerable Periods of Foetal Development Critical periods = finite periods during development in which certain events may occur that will have irreversible effects on later developmental stages A critical period is usually a period of rapid cell division i.e. embryonic/fetal development Neural Tube Defects & Folate Supplements • The neural tube is the embryo's precursor to the CNS. About 20- 28 days after conception, the neural tube closes to form the brain and the spinal cord. If this tube fails to close, a NTD occurs • Folic acid plays an essential role in cellular division. It is also needed for the proper closure of the neural tube • NTDs occur between the 20 - 28th day after conception, before most women know that they are pregnant. Because about half of all pregnancies are unplanned, it is important to include at least 400 mcg of folic acid in every childbearing age woman's diet. (US RDA) Critical Periods Critical periods occur early in development. An adverse influence occuring early can have a much more severe & prolonged impact than one occurring later on. Teratogen Teratogen = any substance, agent or process that induces the formation of developmental abnormalities in a fetus e.g. Thalidomide, alcohol, German measles, cytomegalovirus, irradiation with X-rays, ionising radiation •1957 to 1962 in UK, Canada, Germany, Japan - not FDA approved prevented morning sickness •12,000 babies who survived, with phocomelia (flipper-like arms or legs) Assessing Nutritional Status In Pregnancy Anthropometric measurements • weight, height, BMI, fatfolds, waist circumference?? Biochemical parameters • blood test, urine test – levels of vitamins, minerals, protein?? Clinical assessment • skin, glands, muscle, bones & joints, cardiovascular, gastrointestinal, nervous system?? Dietary intake • 24 hr recall, dietary history, food records, FFQ?? Maternal Weight & Weight Gain Optimal pregnancy outcome (appropriate infant birth weight and well being of both infant & mother) reflects an interaction between gestational weight gain and the pregravid weight status of the mother Underweight mothers – inadequate nutrient reserves to support the critical period of organogenesis & continued fetal growth & development high risk of birth defects, growth restriction (SGA), preterm, foetal & neonatal mortality, maternal complications like antepartum hemorrhage, premature rupture of the membranes & anemia Solution: gain sufficient wt pre-conception & extra wt during pregnancy Overweight mother high risk of medical complications (pregnancy induced hypertension, diabetes mellitus, thromboembolic disease), complicated delivery, post-term birth, late foetal deaths, poor developments in infants Solution: achieve healthy weight pre-pregnancy & avoid excessive weight gain during pregnancy. Postpone weight loss until after childbirth Maternal Weight & Weight Gain Prepregnancy Weight Status BMI Low Recommended total weight gain ranges <19.8 12.5-18 kg Normal 19.8-26.0 11.5-16 kg High 26.0-29.0 7.0-11.5 kg Obese >29.0 > 6.0 kg Mitchell (2003). Nutrition Across the Lifespan. Saunders Mothers underweight before pregnancy had the lowest perinatal mortality when they gained at least 16 kg while obese women had the lowest perinatal mortality when they gained only 7 kg Maternal Weight & Weight Gain If BMI is Weight Status (non-pregnant) Expected Total Weight Gain > 20 Underweight 12 to 18kg 20 ~ 25 Normal healthy weight 11 to 15kg 25 ~ 30 Overweight 6 to 11kg <30 Obese 6 to 9kg Taken from Eating for a Healthy Baby – Food & Nutrition Department, MOH, 1997 Quality of Weight Gain Components of weight gain during pregnancy 64%: maternal tissue & fluid accumulation 25%: foetus 5%: placenta 6%: amniotic fluid wt gain should be the result of a high-quality diet gradual & consistent gains in weight throughout pregnancy foods consumed should be nutritious Special Nutritional Requirements Prior To Pregnancy Good nutritional status before pregnancy is important for successful outcome. Severe undernutrition superimposed on previous marginal nutrition : low fertility rates & if conception occurs – birth defects, preterm births & neonatal deaths Undernutrition that occurs later part of pregnancy less likely to result in birth defects but causes fetal growth restriction & LBW Malnutrition & Foetal Growth & Development After fertilisation: zygote stage (0 - 2 wks) embryonic stage (2 - 8 wks): Hyperplasia (↑in cell no) fetal stage (8 - 38/42 wks): Hyperplasia & hypertrophy (↑ in cell size) Effects of malnutrition depends on the stage of gestation & also duration Malnutrition early in gestation : teratogenic effects during organogenesis e.g. folate with NTDs Malnutrition in last trimester : not teratogenic but restrictions can have serious effects as the fetus gains 2/3 of its full term weight in 3rd trimester - accretion of fat, EFA, calcium, iron, vit E LBW, poorly developed muscles, no subcutaneous fat Malnutrition throughout gestation : affects wt & ht, size of foetus reduced proportionally Risk Factors in Pregnancy Risk factors present at onset of pregnancy: • age • frequent pregnancies • poor obstetric history • poverty • faddist food habits • abuse of nicotine, alcohol, or drugs • therapeutic diet required for a chronic disorder • inappropriate wt (BMI <19.8 or >28) Risk factors occurring during pregnancy: • low haemoglobin • inadequate/excessive weight gain, any weight loss • medical complications Planning Meals For A Pregnant Mother Healthy Diet Pyramid Adults 18-65 Pregnant Rice & Alt 5-7 Meat & Alt 2-3 Fruit 2 Veg 2 6 2 + 1 dairy 2 2+1 green leafy Courtesy of Health Promotion Board Sample Daily Menu for Mother-to-be Sample meal plan No. of servings Rice & alt Breakfast : 2 slices wholemeal bread with thin spread of margarine & jam 1 glass milk Morning snack: 1 small raisin bun Lunch: 1 bowl rice 1 small square beancurd cooked with lean meat & mixed vegetables ¾ mug steamed broccoli 1 wedge papaya Fruit Vege Meat & alt 1 ½ ½ 2 ½ 1 1 1 Sample Daily Menu for Mother-to-be Sample meal plan No. of servings Rice & alt Dinner 1 bowl rice 1 piece grilled fish, palm sized ¾ mug stir-fried kangkog Carrot & potato soup 1 banana Fruit Vege Meat & alt 2 1 1 ½ 1 Supper 2 wholemeal biscuits 1 glass milk ½ Total servings 6 ½ 2 3 3 Adapted from “Eating for a healthy baby” - a healthy eating guide for mother-to-be. Food & Nutrition Department (1997). Ministry of Health, Singapore. Nutrition during Lactation Nutrient requirements by lactating women are greater in amounts when compared to the requirements of non-pregnant women as lactation is a high priority physiological process. Milk Component Biosynthesis • Primary substrates extracted from blood – glucose, amino acids, fatty acids vitamins & minerals. Some mobilized from body stores or synthesized de novo • Quality of milk is maintained at expense of maternal stores (e.g. fat stores, skeletal calcium stores) • Throughout lactation, breast milk changes in composition • Lactation continues as long as adequate suckling stimulation is maintained Roles of Hormones Infant suckling at the breast message to hypothalamus hypothalamus stimulates anterior pituitary to release prolactin (promotes milk production by alveolar cells of mammary glands) Effect on reproductive organs: prolactin inhibit ovulation Nutritional Requirements during Lactation Energy Singapore RDDA Women Energy (Nonpregnant) Light Moderate Heavy Energy (Pregnant) Full activity Reduced Energy (BF) 1st 6 After 6 mth mth 18-30 2000 2100 2350 +285 +500 30-60 2050 2150 2350 +200 +500 Macronutrients Singapore RDDA Protein, g CHO, g Fat, g Women 18-30 58 275 56 Women 30-60 58 282 57 Pregnant –full activity +9 +39 +8 Pregnant –reduced +9 +28 +6 BF 1st 6 mth +25 +69 +14 BF After 6 mth +19 +69 +14 Protein: Based on protein content of 11g/l of projected milk volumes. Protein intakes do not appear to significantly volumes but severe restrictions may alter content of some nitrogen-containing compounds Lipids: dietary alterations do not appear to affect the amount of fat in the milk but women with low fat stores appear to secrete milk with lower fat content. Important – type of fatty acids (linoleic, α-linolenic) to support CNS & retina development Vitamins & Minerals Singapore RDDA Ca, Women 18-30 800 Women 30-60 mg Phos, mg Vit D, mcg B12, mcg Folate, mcg Iron, mg 1200 2.5 2.0 200 19 800-1000 800 2.5 2.0 200 19 Pregnant –full activity 1000 1200 10.0 3.0 400 19 Pregnant –reduced 1000 1200 10.0 3.0 400 19 BF 1st 6 mth 1000 1200 10.0 2.5 300 19 BF After 6 mth 1000 1200 10.0 2.5 300 19 Planning Meals For A Lactating Mother Healthy Diet Pyramid Rice & Alt Meat & Alt Fruit Veg 5-7 2-3 2 2 Pregnant 6 2 + 1 dairy 2 2 + 1 green leafy Lactating 6-7 2 + 1 dairy 2 3 Adults 18-65 Importance of Preparatory Support to Promote Breastfeeding Breastfeeding Support Groups Breastfeeding Mothers' Support Group (Singapore) 96 Waterloo Street #02-04 SCWO Centre, Singapore 187967 http://www.breastfeeding.org.sg/ http://www.lalecheleague.org/ Breastfeeding Information The Growing Years (Infant, Toddler, Pre-schooler, School-aged Children, Adolescent) Age ranges: Infant = birth to 1 yr Toddler = 1 to 2 years Preschooler = 2 to 6 years • Dramatic changes in 1st yr • Period of most rapid growth • Changes in food & feeding abilities School-age girls = 7 - 10 years School-age boys = 7 - 12 years Great diversity in size, age, growth rates & developmental skills C_____________ = a period between infancy & adolescence Infant Weight Gain - First 5 Years 15 10 5 0 1 2 3 4 5 Indicators Of Nutritional Status Developmental problems Head circumference-for-age Stunting/shortness Stature/height-for-age Underweight BMI-for-age Weight-for-length/stature Overweight BMI-for-age Weight-for-length/stature Risk of overweight BMI-for-age Weight-for-length/stature <5th percentile >95th percentile <5th percentile <5th percentile >95th percentile >85th to <95th percentile Sequence of Development of Feeding Behavior Age Reflexes Motor Dev Feeding Bhv Food 1-3 mths Rooting, suck & swallow reflexes present at birth Poor head control →→head stable Hands fisted →→holds toys Secures milk with suckling pattern →→opens mouth/ anticipates feeding Breast milk or infant formula 4-6 mths Rooting reflex fades. Tongue thrust present if spoon feeding attempted →→reduced Palmar grasp – to bring objects to mouth Supported sitting Suckling strength increases Chewing motion begins (gumming food) Mouth open for spoon, bring hands to bottle, holds, sucks & bites cookies Strained, pureed or blenderised food from spoon →→ mashed food without lumps Sequence of Development of Feeding Behavior Age Reflexes Motor Dev Feeding Bhv Food 7-9 mths Gag reflex weaker Bears weight on legs when held Sits briefly alone Holds one object in each hand Develop inferior pincer grasp Tries to finger feed soft food Use tongue to move lumps of food Holds bottle alone, cup drinking Munching/chewing movements when solid foods eaten, rotary chewing begins Mashed lumpy foods by spoon, large pieces of easily chewed finger foods Tooth eruption continues, chewing matures Bites nipples/teats, spoons & crunchy foods Finger feeds with refined pincer grasp Continue addition of new food with easy-tochew texture 10 - 12 mths Nutrient Needs Rapid growth & major changes in body composition: high energy & nutrient demands o most nutrient needs of infants, in proportion to body weight, is > double that of adults o example: Infant Adult Energy (kcal/kg/day) 90 – 120 Protein (g/kg/day) 1.6 – 2.2 > 30 – 40 > 0.8 – 1 impossible to establish a single standard for all infants o recommendations expressed as ranges e.g. for birth - 6 mths & 6 mths - 1 year If maternal diet is adequate, breast milk will meet the major nutrient needs of the baby Infant Feeding Patterns 3 overlapping stages: Nursing period o Breast milk/ formula provides complete for the infant (4 - 6 mths after birth) nutrition As physical & developmental capabilities mature, Transitional period o Specially prepared semi-solid foods are introduced, composition & consistency progressively o Breast milk/ formula continues Modified adult period o Eating a variety of foods from a mixed diet (1/3 – ½ of dietary intake) Recommended Supplementary Food Introductions During The 1st Year Food 4-6 mths 6-8 mths Breast milk/ iron fortified infant* formula 4-6 feeds 3-4 feeds * follow up formula Rice/Cereals Iron fortified rice cereals, potato Infant cereals – mixed, teething biscuits Fruit Pureed, strained fruits; juices (diluted) Mashed/scraped lumpy fruits Vegetables Pureed, strained vegetables Mashed/scraped lumpy vegetables Meats Scraped/mashed/finely minced meats; scraped /mashed egg yolk, tofu Food 8-10 mths 10-12 mths Breast milk/ iron fortified follow up formula 3-4 feeds 3-4 feeds Cereals Other cereals, plain crackers, thin porridge Breads, soft rice, pasta, thick porridge Fruit Soft peeled fruits (mashed/chopped) Small pc soft, fresh, canned fruits (unsweetened) Vegetables Mashed/chopped vegetables Small pc tender-cooked veges; raw – finger foods Meats Plain baby yogurt; mashed/finely minced meats, cooked legumes mashed Mashed/finely minced /chop/tender-cooked meats; mild cheeses Planning Meals For Older Infants Healthy Diet Pyramid Guide 7-12 months Rice & Alt Meat & Alt Fruit Veg 1-2 servings ½ serving ½ serving ½ serving To include additional 750 ml milk Nutrition in Adolescence Stages of the life cycle an adolescent has gone through… Assessment of Nutritional Status Three important features of the adolescent growth spurt that must be considered are time of onset, duration & magnitude Anthropometry – monitoring of growth /growth velocity is one of the most sensitive means for evaluation Assessment may be complicated by the fact that ratio of LBM and fat to height changes Crossing from one growth channel to another occurs frequently during this period of rapid growth – when two or more channels are crossed, further evaluation is necessary Assessment of Nutritional Status Knowing the stage of sexual maturity ratings helps in evaluation of nutritional significance of growth deviation – e.g. 85th percentile weight & skinfold for a girl at stage 1 indicates weight & fat accumulation preceeding pubertal growth spurt for a girl at stage 4 indicates excess body fat that may continue into adulthood Clinical – because of their rapid growth, adolescents’ nutrition deficiencies become apparent more quickly than do adults’. Physical signs reflect advanced stages of undernutrition Nutritional Requirements in Adolescence High Nutrient Needs Except for the first 2 years of life, there is no time when growth & development are as rapid Onset of puberty & adolescent growth spurt demands for energy, macronutrients, vitamins & minerals increase markedly Adolescence may serve as a window of opportunity for compensating for early childhood growth failure – nutrient intake must be favourable. However the potential for significant catch-up growth is limited Planning Meals For Adolescents Factors to consider: stage of growth/development gender & nutritional requirements Ensure that all nutrients are provided with a variety of foods balanced among the food groups in the Healthy Diet Pyramid Appropriate snacks – nutrient dense choices (low fat/skim milk & dairy products, fresh fruits /vegetables & juices, sandwiches with wholegrain breads & lean meats/low fat cuts) should be provided Calcium & iron-rich sources should be emphasized Planning Meals For Adolescents Healthy Diet Pyramid Age Rice & Alt Meat & Alt Fruit Veg 7-12 yrs 5-6 (this includes 1 serving of whole grains) 2 (include 250-500 ml in addition to the 2 svgs above) 2 2 13-18 yrs 6-7 (this includes 1 serving of whole grains) 2 (include 250-500 ml in addition to the 2 svgs above) 2 2 18-65 yrs 5-7 2-3 2 2 Stages of Adulthood 20 – 30s 40 – 50s 60 – 80s The Early Years The Middle Years The Older Years 55 Dietary Recommendations For The Healthy Adult Carbohydrate Protein Fat 50 - 60% of calories 10 - 20% of calories 25 - 30% of calories Refer to the following: “Dietary Guidelines 2003 for Adult Singaporeans (18-65 years)” HPB MOH Topic 2: Dietary Practices & Meal Planning for Healthy Diet Pyramid Guide 56 Planning Meals For Adults Rice & Alt Meat & Alt Fruit Vege Men (Light Activities) 7 3 2 2 Women (Light Activities) 5-6 3 2 2 Young adults should choose heart-healthy diets to protect themselves against CVD in later years For adults on vegetarian or macrobiotic diets, refer to Topic 2 notes 57 Planning Meals With Less Fat Mr Lim usually has … If he orders … He saves … Breakfast 2 pc roti prata w dhall curry Breakfast 2 pc toast w jam 7.6 – 2 = 5.6 g Lunch Chicken rice Lunch Plain rice Chicken roasted (skinless) Stir-fried mix vege 26.0 g – 8 = 18 g Afternoon Tea 2 pc currypuff, potato Afternoon Tea 2 pc popiah, 43.9 – 22.4 = 21.5 g Dinner Pork chop, 2 pc Cream of mushroom soup Black forest cake Dinner Broiled pork tenderloin, 6 oz, lean only Broth Fat-free ice cream 66.7 g -10 = 56.7 g Supper ½ c mixed nuts Supper 2 pc fresh fruits 27.7 g - 0 = 27.7 g Saves 129.5 g fat !! 58