1. NUTRITION Level 3, Academic Year (AY) 1434—1435 H Mylin G. Abalus, MSN Lecturer

2. Learning Objectives: Identify the nutritional needs of pregnant women, lactating women, infants, children, adolescents and adults. Discuss the nutritional needs of patients with health problems and the corresponding dietary management. Department of Nursing2

3. Topic Outline 1.Nutrition during Pregnancy and Lactation 2.Nutrition during Infancy 3.Nutrition during Childhood 4.Nutrition during Adolescents 5.Nutrition During Adulthood 6.Nutrition for Patients with Health Problems with Associated Nutritional Problems

4. Energy and Nutrient Needs during Pregnancy Nutrient needs during pregnancy and lactation are higher than at any other time. To meet the high nutrient demands of pregnancy, a woman will need to make careful food choices Department of Nursing4

5. Energy and Nutrient Needs during Pregnancy Energy – Second trimester- +340 cal – 3 rd trimester-+450 cal Represents about 15-20% in 2000-kcal daily intake Department of Nursing5

6. Energy and Nutrient Needs during Pregnancy Suggested foods: whole-grain breads and cereals, legumes, dark green vegetables, citrus fruits, low-fat milk and milk products, and lean meats, fish, poultry, and eggs. CHO- 135- 175 grams or more per day is necessary to fuel the fetal brain. Sufficient carbohydrate ensures that the protein needed for growth will not be broken down and used to make glucose Department of Nursing6

7. Energy and Nutrient Needs during Pregnancy Protein + 25 grams per day higher than for non-pregnant women. Suggested food sources: meats, milk products, and protein-containing plant foods such as legumes, whole grains, nuts, and seeds. Use of high-protein supplements during pregnancy may be harmful to the infant’s development, it is discouraged. Department of Nursing7

8. Energy and Nutrient Needs during Pregnancy Essential Fatty Acids essential long-chain polyunsaturated fatty acids are particularly important to the growth and development of the fetus brain is largely made of lipid material, and it depends heavily on fatty acids for its growth, function, and structure Department of Nursing8

9. Energy and Nutrient Needs during Pregnancy Sources of Omega-3 and Omega-6 Fatty Acids Omega-6 Vegetable oils (corn, sunflower, safflower, soybean, cottonseed), poultry fat, nuts, seeds, Meats, poultry, eggs (or can be made from linoleic acid) Omega-3 Oils (flaxseed, canola, walnut, wheat germ, soybean) Nuts and seeds (butternuts, flaxseeds, walnuts, soybean kernels) Vegetables (soybeans), anchovy, herring, lake trout, sardines, tuna) (or can be made from linolenic acid Department of Nursing9

10. Energy and Nutrient Needs during Pregnancy Nutrients for Blood Production and Cell Growth folate, vitamin B12, iron, and zinc- important in the synthesis of DNA and new cells. Folate Recommended Dietary Allowance (RDA) during pregnancy: 600 μg/day Vitamin B12 RDA during pregnancy: 2.6 μg/day Department of Nursing10

11. Energy and Nutrient Needs during Pregnancy Folate sources: from a combination of supplements, fortified foods, and a diet that includes fruits, juices, green vegetables, and whole grains Vitamin B12 sources: meat, fish, eggs, or milk Department of Nursing11

12. Energy and Nutrient Needs during Pregnancy Iron RDA during pregnancy: 27 mg/day Iron is needed to support their enlarged blood volume and to provide for placental and fetal needs daily iron supplement recommended during the second and third trimesters- 30 to 60 milligrams supplement should be taken between meals or at bedtime and with liquids other than milk, coffee, or tea, which inhibit iron absorption Vitamin C or orange juice can enhance absorption Department of Nursing12

13. Energy and Nutrient Needs during Pregnancy Zinc RDA during pregnancy:12 mg/day (18 yr); 11 mg/day (19–50 yr) required for DNA and RNA synthesis and thus for protein synthesis and cell development. Department of Nursing13

14. Energy and Nutrient Needs during Pregnancy Nutrients for Bone Development Vitamin D and the bone-building minerals calcium, phosphorus, magnesium, and fluoride are in great demand during pregnancy. The Adequate Intake (AI) for vitamin D and calcium does not increase during pregnancy Sources: Regular exposure to sunlight and consumption of vitamin D–fortified milk, cheese, yogurt, and other calcium-rich foods. Less preferably, they may need a daily supplement of 600 milligrams of calcium. Vitamin D plays a vital role in calcium absorption and utilization Department of Nursing14

15. Energy and Nutrient Needs during Pregnancy The recommended intake of fiber for pregnant women is 28 g/day No need to increase vitamin A. Vitamin E requirement increases for all ages (from 8 to 10  g). Vitamin K requirement remains the same for women 25 and older (65  g), but dramatically increases for girls 11-14 (from 45  g to 65  g). Requirements for all the water-soluble vitamins are increased. Department of Nursing15

16. Maternal energy and Nutrient during Lactation Energy requirement during lactation: 1st 6 mo: +330 kcal/day 2nd 6 mo: +400 kcal/day Fiber- + 1 g Department of Nursing16

17. Maternal energy and Nutrient during Lactation See figure on Comparison of Nutrient Recommendations for Non-pregnant, Pregnant, and Lactating Women (Understanding Nutrition by Whitney and Rolfes) See figure on Dietary Reference Intake for lactating women (Understanding Nutrition by Whitney and Rolfes) Department of Nursing17

18. M Department of Nursing18

19. Post-Lecture Evaluation 1.Energy needs during pregnancy increase by about: a. 100 kcalories/day. b. 300 kcalories/day. c. 500 kcalories/day. d. 700 kcalories/day. Department of Nursing19

20. Post-Lecture Evaluation 2. Pregnant women should not take supplements of: a. iron. b. folate. c. vitamin A. d. vitamin C. Department of Nursing20

21. Nutrition During Infancy During the first year, the normal child needs about 100 kcal per kilogram of body weight each day. Infants up to 6 months of age should have 2.2 g of protein per kg of weight each day; age 6- 12 months should have 1.56 g of protein per kg of weight each day. This is satisfactorily supplied by human milk or infant formulas Department of Nursing21

22. Nutrition During Infancy Iron-fortified cereal is usually started at about 6 months. A vitamin K supplement is routinely given shortly after birth. Infants should not be given an excess of vitamin A or D. Vit A can damage the liver and cause bone deformities, Vit D can damage the cardiovascular system and the kidneys Department of Nursing22

23. Nutrition During Infancy minimum of 30g of fat per day Human milk contains generous amounts of essential fatty acids water intake -1.5 ml/kcal/day Department of Nursing23

24. Nutrition During Infancy Essential vitamins and minerals can be supplied in breast milk, formula and food except for Vitamin D |(it is necessary to expose infants to sunlight on a regular basis). Vitamins: Vitamin C- human milk, fortified formula; Vitamin K- given shortly after birth Department of Nursing24

25. Nutrition During Infancy Guidelines in Feeding – Breastfeeding Breast should be offered every 2 hours in the first few weeks. The infant should nurse 10-15min on each breast. Growth spurts occur at about 10 days, 2 weeks, 6 weeks, and 3 months; infant may nurse more frequently. Department of Nursing25

26. Nutrition During Infancy Indications of adequate nutrition include: – The infant has six or more wet diapers per day. – The infant has normal growth. – The infant has one or two mustard-colored bowel movements per day. – The breast becomes soft during nursing Department of Nursing26

27. Nutrition During Infancy Bottle Feeding – The infant should be cuddled and held in an upright position. – He should be burped to prevent regurgitation. – Formulas are developed so that they are similar to human milk in nutrient and kcal values. Burping a Baby: Department of Nursing27

28. Nutrition During Infancy Sterile water must be used to mix formula. Infants under one year should not be given regular cow’s milk. Consistent temperature should be used. Infants should not be put to bed with bottle. Department of Nursing28

29. Nutrition During Infancy Supplementary Foods Limit diet to breast milk until the age of 4 to 6 months. Cow’s milk should be avoided until after one year of age. Solid foods should not be introduced before 4 to 6 months of age and should be done gradually. Department of Nursing29

30. Nutrition During Infancy The general guidelines for the introduction of solid foods are as follows: – Introduce iron-fortified rice cereal at six months and no younger than 4 months – Add pureed vegetables and fruits at about 7-8 months – Add pureed meat at 8-9 months – Add juice when the infant is old enough to drink from a cup, at about 9-10 months – Add foods with more texture and finger foods at 9-10 months (chopped meats, crackers, etc) – Add allergenic foods like egg whites, whole milk, wheat products and orange juice after 1 year – Honey should never be given to an infant because it could be contaminated with Clostridium botulinum bacteria Department of Nursing30

31. Nutrition During Infancy Indications for Readiness for Solid Foods – Ability to pull food into the mouth rather than pushing the tongue and food out of the mouth. – Willingness to participate in the process. – Ability to sit up without support. – Having head and neck control. – The need for additional nutrients. – Drinking more than 32 ounces of formula or nursing 8 to 10 times in 24 hours. Department of Nursing31

32. Nutrition During Childhood Nutritional Requirements during childhood – The suggested intake proportion of energy for children is: – 50% - 60% carbohydrate – 25% - 35% fat – 10% - 15% protein – Nutrient needs increase because of increase in body size. – Need 2 to 3 cups of milk or equivalent in terms of calcium per day. – Minimize sweets. – Limit sweetened fruit juices. – Drink 1 ml of water for each kcal of food. Introduce fiber slowly. Department of Nursing32

33. Nutrition During Childhood Protein – The need for protein per kg body weight decreases from approximately 1.1 g in early childhood to 0.95 g in late childhood – Minerals and vitamins Fe – children between 1 and 3 years of age are at high risk of developing IDA Ca – 500 mg/day for children 1-3 years, 800 mg/day for children 4- 8 years and 1300 mg/day for 9-13 years Zn – an allowance of 3 mg/day for children 1-3 years, 5 mg/day for children 4-8 years and 8 mg/day for children 9-13 years. Because thebestsources for Zn are meats and seafood, children usually have low intake. Vit D – the best source of vit D is also from milk. Children living in tropical areas do not need Vit D supplementation. Department of Nursing33

34. Nutrition During Adolescents Except for Vitamin D, nutrient needs increase dramatically at the onset of adolescence. Because of menstruation, girls have a greater need for iron than do boys. Adolescents may prefer to imitate their peers. Calculation of caloric requirement: 80 kcal/kg of body weight for prepubescent children 45 kcal/kg of body weight for active adolescent males 38 kcal/kg of body weight for active adolescent females Department of Nursing34

35. Nutrition During Adolescence Protein – Protein intake must be increased to make up for the fast growth and development of body organs Calcium – The recommended dietary intake of calcium for adolescents is 1200 to 1500 mg. – Greater need for boys than girls Iron – All adolescents have high requirement for iron. The build- up of muscle mass in boys is accompanied by greater blood volume, and girls lose iron monthly with the onset of menses Department of Nursing35

36. Nutrition During Adolescence Zinc – It is known to be essential for growth and sexual maturation. Vitamins – Because of tissue synthesis, the body has an increased demand for vitamin B 6, folic acid, and vitamin B 12. It also needs more vitamin D for rapid skeletal growth and vitamins A, C, and E for new cell growth. Department of Nursing36

37. Nutrition During Adulthood Nutritional Requirements for adults – focuses on maintaining health by using food, particularly plant-based foods and their constituents, to optimize the function of the digestive and liver detoxification systems and other organs in the body including the immune system. The iron requirement for women is higher than men until after menopause Department of Nursing37

38. Nutrition During Adulthood Protein requirement for adults is 0.8 g per kilogram of body weight. Current requirement for calcium for adults from 19-50 is 1,000 mg. Vitamin D requirement is 5  g per day. Both calcium and vitamin D are essential for strong bones, and both are found in milk. Department of Nursing38

39. Nutrition During Adulthood Three glasses of milk per day fulfill the calcium and vitamin D requirements. Bone loss begins slowly, at about the age of 35 to 40. Kcal requirements begins to diminish after the age of 25. Basal metabolic rates are reduced by 2 to 3% a decade. Determined primarily by activity and amount of lean muscle mass. Department of Nursing39

40. Nutrition During Adulthood Nutritional Requirements for old adults – Follow a modified food guide pyramid for individuals 70 and older. – Protein requirement remains at the average 50 g per day for women and 63 g for men. Department of Nursing40

41. Nutrition During Adulthood This is based on 0.8 g per kg of body weight. After age 65, it may be advisable to increase one’s daily protein intake to 1.0g per kg of body weight. Vitamin requirements do not change after the age of 51, except for a slight decrease in the RDAs for thiamin, riboflavin, and niacin because of decreased kcal intake. The need for iron is decreased after age 51 in women because of menopause. The kcal requirement decreases approximately 2 to 3% a decade because metabolism slows and activity is reduced. Department of Nursing41

42. Nutrition During Adulthood Nutrition Related concerns Osteoporosis – Condition in which the amount of calcium in bones is reduced, making them porous. – Bone density scan can be done with a special X-ray to determine if one has osteoporosis. – Sedentary life coupled with a diet deficient in calcium, vitamin D, and fluoride and estrogen loss contribute to the condition. – Estrogen replacement therapy (ERT), 1,500 mg of calcium, and exercise are possible preventative measures. – Another possible cause of osteoporosis may be a diet (Sodas, coffee, tea and processed foods) containing excessive amounts of phosphorus, which can speed bone loss. – Good sources of calcium: milk products Department of Nursing42

43. Post-lecture Evaluation An infant should begin eating solid foods between: a. 2 and 4 weeks. b. 1 and 3 months. c. 4 and 6 months. d. 8 and 10 months

44. Post-lecture Evaluation To balance the day’s intake, an adolescent who eats a hamburger, fries, and cola at lunch might benefit most from a dinner of: a. fried chicken, rice, and banana. b. ribeye steak, baked potato, and salad. c. pork chop, mashed potatoes, and apple juice. d. spaghetti with meat sauce, broccoli, and milk. Department of Nursing44

45. Post-lecture Evaluation During adolescence, energy and nutrient needs: a. reach a peak. b. fall dramatically. c. rise, but do not peak until adulthood. d. fluctuate so much that generalizations can’t be made. Department of Nursing45

46. Post-lecture Evaluation On average, adult energy needs: a. increases b. Declines gradually c. remain stable throughout life. d. rise gradually throughout life. Department of Nursing46

47. References Whitney, W & Rolfes, SR (2008) Understanding Nutrition (11 th ed), Thomson Higher Education, Belmont, CA, USA. Caudal, ML. (2008) Basic nutrition and diet therapy textbook for nursing students /. Rev. ed. Quezon City : C & E Pub. Grodner, M. et al. (2009). Foundations and Clinical Application of Nutrition: A Nursing Approach. 4 th Edition.

48. Topic for the Next Session Unit IV. Diet Therapy Definition of Diet Therapy Diet Therapy Determination (Indications) and Identification