Nutrition Across the Life Span

Elderly

Adult

Adolescence

Pregnancy

Infant

Child

• Growth

• Development

• Prevent disease

• Promote health

• Prolong life

Role of Nutrition

Nutrition in Pregnancy

Stages of Pregnancy & Birth Stages of Pregnancy & Birth

Preconception = before pregnancy

Periconception = 1→3 months before pregnancy to the first 6 weeks after delivery

370 2 8 20 4038 42 44

Fertilization Birth

GESTATION

TermPretermPostterm

Prenatal or Antenatal

Postnatal or postpartum

28

Perinatal

Zygote Embryo Fetus

Neonate

Infant

Terms for Stages surrounding Pregnancy and Birth

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

• 1st trimester additional energy requirement is small

• 2nd / 3rd trimester + + 200 - 300 k200 - 300 kccalal/day/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

China RNI Energy (Nonpregnant)

Light Moderate Heavy

Energy (Pregnant)

Full activity Reduced

Women 18-55 2100 2100 2350 +285 +200

Women <55 2050 2150 2350

• 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

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

• 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

Macronutrient Needs

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

Critical Periods

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

Vulnerable Periods of Foetal Development

Neural Tube Defects & Folate SupplementsNeural 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 c

ord. If this tube fails to close, a NTD occurs

• Folic acid plays an essential role in cellular division. It is also needed for t

he proper closure of the neural tube

• NTDs occur between the 20 - 28th day after conception20 - 28th day after conception, before most wom

en know that they are pregnant. Because about half of all pregnancies ar

e unplanned, it is important to include at least 400 mcg of folic acid in eve

ry childbearing age woman's diet. (US RDA)

Critical periods occur early in development.

An adverse influence occuring early can have a much more severe

& prolonged impact than one occurring later on.

Critical Periods

TeratogenTeratogen

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

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

Prepregnancy Weight Status BMI Recommended total weight gain ranges

Low <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 kgMitchell (2003). Nutrition Across the Lifespan. Saunders

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

Maternal Weight & Weight Gain

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 Good nutritional status before pregnancy is important for

successful outcome.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

Healthy Diet Pyramid

Courtesy of Health Promotion Board

Planning Meals For A Pregnant Mother

Rice & Alt Meat & Alt Fruit Veg

Adults

18-65

5-7 2-3 2 2

Pregnant 6 2 + 1 dairy 2 2 + 1 green leafy

Sample Daily Menu for Mother-to-beSample Daily Menu for Mother-to-be

Sample meal plan No. of servings

Rice & alt Fruit Vege Meat & alt

Breakfast :

2 slices wholemeal bread with thin spread of margarine & jam

1 glass milk

1

½

Morning snack:

1 small raisin bun ½Lunch:

1 bowl rice

1 small square beancurd cooked with lean meat & mixed vegetables

¾ mug steamed broccoli

1 wedge papaya

2

1

½

1

1

Sample Daily Menu for Mother-to-beSample Daily Menu for Mother-to-be

Adapted from “Eating for a healthy baby” - a healthy eating guide for mother-to-be. Food & Nutrition Department (1997). Ministry of Health, Singapore.

Sample meal plan No. of servings

Rice & alt Fruit Vege Meat & alt

Dinner

1 bowl rice

1 piece grilled fish, palm sized

¾ mug stir-fried kangkog

Carrot & potato soup

1 banana

2

1

1

½

1

Supper

2 wholemeal biscuits

1 glass milk

½

½

Total servings 6 2 3 3

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 BiosynthesisMilk 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 Roles of Hormones

Infant suckling at the breast message to hypothalamus

hypothalamus stimulates anterior pituitary to release prolactin (p

romotes milk production by alveolar cells of mammary glands)

Effect on reproductive organs: prolactin inhibit ovulation

Nutritional Requirements during Lactation

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 +200 +500 +500

30-60 2050 2150 2350

Energy

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

Macronutrients

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

Singapore RDDA Ca, mg Phos, mg

Vit D, mcg

B12, mcg

Folate, mcg

Iron, mg

Women 18-30 800 1200 2.5 2.0 200 19

Women 30-60 800-1000 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

Vitamins & Minerals

Planning Meals For A Lactating Mother

Healthy Diet Pyramid

Rice & Alt Meat & Alt Fruit Veg

Adults 18-65 5-7 2-3 2 2

Pregnant 6 2 + 1 dairy 2 2 + 1 green leafy

Lactating 6-7 2 + 1 dairy 2 3

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

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

• Dramatic changes in 1st yr

• Period of most rapid growth

• Changes in food & feeding abilities

Infant Weight Gain - First 5 YearsInfant Weight Gain - First 5 Years

0 1 2 3 4 5

5

15

10

Indicators Of Nutritional StatusDevelopmental problems

Head circumference-for-age

Stunting/shortnessStature/height-for-age

UnderweightBMI-for-age Weight-for-length/stature

OverweightBMI-for-ageWeight-for-length/stature

Risk of overweightBMI-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

10 - 12 mths

Tooth eruption continues, chewing matures

Bites nipples/teats, spoons

& crunchy foods

Finger feeds with refined

pincer grasp

Continue addition of new food with easy-to-chew texture

Nutrient Needs

Rapid growth & major changes in body composition:

high energy & nutrient demandso most nutrient needs of infants, in proportion to body weight, is >

double that of adultso example: Infant Adult

Energy (kcal/kg/day) 90 – 120 > 30 – 40

Protein (g/kg/day) 1.6 – 2.2 > 0.8 – 1

impossible to establish a single standard for all infantso 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:3 overlapping stages:

Nursing period

o Breast milk/ formula provides complete nutrition for the infant (4 - 6 mths after birth)

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)

o Breast milk/formula still main source of energy & nutrients (by 12 mths)

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

Rice & Alt Meat & Alt Fruit Veg

7-12 months 1-2 servings ½ serving

To include additional 750 ml

milk

½ serving ½ serving

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 AdolescentsHealthy 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

55

Stages of Adulthood

The The EarlyEarly Years Years20 – 30s

40 – 50s The The MiddleMiddle Years Years

60 – 80s The The OlderOlder Years Years

56

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

Dietary Recommendations For The Healthy Adult

Carbohydrate 50 - 60% of calories Protein 10 - 20% of calories Fat 25 - 30% of calories

57

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

58

Planning Meals With Less FatMr 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

Saves129.5 g fat !!