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This document contains Chapters 17 to 18 Chapter 17 Nutrition During the Growing Years Overview Chapter 17 describes the patterns of growth and development that occur from infancy through adolescence, including changes in height, weight, body composition, and organ development. Assessments of growth are the best indicators of nutritional status. The consequences of malnutrition at various stages of growth and development are presented. Energy requirements, nutrient needs, and nutrition-related problems associated with each stage of development are discussed. For infants, human milk and formula are compared and introduction of solid foods is described. For young children, the authors suggest several methods of coping with food jags, food refusal, and picky eating. For older children and adolescents, the focus shifts to encouraging healthy food choices and physical activity to encourage optimal growth and prevent chronic diseases later in life. Learning Objectives Describe normal growth and development during infancy, childhood, and adolescence and the effect of nutrition on growth and development. Describe the calorie and nutrient needs of infants, children, and adolescents. Compare the nutritional qualities of human milk and infant formula. Explain the rationale—from the standpoints of both nutrition and physical development—for the delay in feeding infants solid foods until 4 to 6 months of age. Describe the recommended rate and sequence for introducing solid foods into an infant’s diet. Discuss the factors that affect the food intake of children and adolescents. Plan nutritious diets for infants, children, and adolescents using MyPlate. Describe the nutrition-related problems that may occur during the growing years and their impact on future health. Teaching Strategies, Activities, Demonstrations, and Assignments Assign students the Take Action activity, "Getting Young Bill to Eat.” Use it as a basis for a discussion of typical problems infants, toddlers, and children have with eating. Discuss strategies for overcoming these problems and promoting good eating habits. Assign students the Take Action activity, “Evaluating a Teen Lunch.” Use it as a springboard for discussing nutritious meals and snacks for teens. Present case studies of an infant, a toddler, and a child with typical eating problems. Duplicate these case studies. Divide the class into small groups. Assign a group leader and give him/her a copy of the studies. Have each group come up with strategies for solving the eating problems in each case. Take one case at a time and let each group leader present the strategies determined by each group. Make a list of these on the blackboard. This would be a good critical thinking activity. Have students bring examples of how certain packaged foods are expressly marketed to young children. Ask them to evaluate the nutritional value of these foods. Have students visit a supermarket to survey the availability of foods for infants. Ask them to compare various brands based on cost and quality. They could compare ingredients using the order given on the label, serving size, and cost. Include fruits, vegetables, meats, mixed dishes, cereals, juices, and dessert items. Assign students the task of planning a menu for a 7-12-year-old child and a teenager using the Dietary Guidelines for Americans 2010. Have students visit a local pharmacy to determine the content and cost of nutrient supplements for infants, preschool children, and school-age children. What products contain fluoride and how can they be obtained? Do any of the supplements have vitamin and mineral levels above 150% of the US RDA? Are generic brands cheaper than commercial brands? By how much? Are they similar in nutrient content or not? Which one would they pick if they had a child? Have them discuss their answers in class. Ask a representative of the WIC Program to come and discuss the program with the class. Have students devise games and game boards for teaching children nutrition facts. These games can be used in physician’s waiting rooms, schools, daycares, or at home. Have students conduct a community-wide survey of foods in vending machines in public places and comment on their nutritional value. Also have students comment on how often they purchase vending machine food and how they can improve their diets by avoiding these foods. Have students compile a 3-day menu of the meals typically eaten in the family they grew up in. Ask them to evaluate the nutrition of those food choices. Have them use the family menu to create a shopping list and visit a grocery store to determine the cost for purchasing the ingredients. They can also look for substitutions and ways to make these same meals more nutritious. Lecture Outline Growing Up General Ability to thrive (grow and develop to the fullest physical and mental genetic potential) is dependent on Calorie and nutrient intake Adequate sleep Loving care Effects of poor diet depend on severity, timing, and duration If hormonal and other conditions have passed, good nutrition cannot make up for lost growth Height and Weight Infancy Physical growth rate is at peak velocity Nutrient needs per unit body weight are at lifetime highest point By 4 - 6 months, birth weight doubles By 1 year, birth weight triples, length increases by 50% Childhood Slower growth rate Growth occurs in bursts Nutrient and calorie needs and appetite rise and fall in response to normal growth fluctuations Height increases each year by a few inches Weight increases each year by 4 - 6 lbs. until age 8 or 9, then increases to 8 - 10 lbs./year until puberty Adolescence Transition from childhood to adulthood Rapid phase of physical growth (1/3 of all lifetime growth) Puberty: child matures into an adult capable of reproduction; initiated by secretion of sex hormones Girls: begins at age 10 - 13, lasts 8 - 10 years Boys: begins at age 12 - 15 lasts 8 - 10 years Growth rate peaks about 18 months after puberty begins Girls usually have rapid height increases at age 11 and attain adult height within 2 years after menarche; total 10” Boys usually have rapid height increases at age 13 - 14 and attain adult height by age 18; total 12” Body Composition Proportion of body water declines during first 2 - 3 years of life, then reaches levels similar to adults Proportion of lean body mass increases throughout infancy and childhood During adolescence, males secrete testosterone and gain more muscle mass than females (2/3 as much lean body mass as males) Proportion of body fat Rises until age 1 Declines between ages 1 - 7 Age 7, gradually increases to prepare for puberty During adolescence Due to action of estrogen, females continue to deposit body fat, which is essential for sexual maturation and reproduction When body fat = 16 - 17% and body weight is ~100 lbs., menstruation begins Body fat declines in males during adolescence By end of adolescence, females have twice as much body fat (as a percent of body weight) as males Restriction of dietary intake among infants, children, and adolescents is not advised Most obese infants become normal-weight preschoolers without excessive dietary restrictions Risk of stunted growth and development Body Organs and Systems Infancy Kidneys double in size, function more efficiently Stomach increases capacity and begins secreting digestive enzymes GI tract matures to enable larger food intakes and greater variety of foods Childhood Many organs reach full adult size Brain growth is ¾ complete by age 2, finished by age 6 - 10 Heart reaches adult size and respiratory system reaches adult function by age 9 Digestive system matures to efficiently absorb nutrients, build nutrient stores Adolescence Completion of organ system maturation Half of peak bone mass is accrued during adolescence Development of reproductive system and secondary sexual characteristics Physical Growth General Growth is best indicator of nutritional status Percentile: ranks individuals in a group of others of the same age and gender Growth depends on dietary intake and genetic potential Birth to 36 months Weight-for-age Length-for-age Weight-for-length Head circumference-for-age Ages 2 - 20 Weight-for-age Stature-for-age BMI-for-age Tracking Growth It takes 2 - 3 years to establish infant’s percentile, then child usually tracks along same percentile throughout childhood and adolescence Preterm infants may move up several percentiles if they experience “catch-up” growth Small spurts and lags are expected, but jumping up or down 2 or more percentiles may signal growth problems caused by nutrient excesses or deficits, illness, or psychological problems Indicators of nutritional status At risk for developmental problems 0 to 2 years: head circumference-for-age 95th percentile Stunted growth 0 - 2 years: length-for-age <5th percentile 2 - 20 years: stature-for-age <5th percentile Underweight 0 - 2 years: weight-for-length 95th percentile Obese 2 - 20 years: BMI-for-age >95th percentile BMI ≥30 Using Growth Chart Information Changes in BMI-for-age or weight-for-length reflect increases or decreases in recent nutritional status (before height is affected) Stature-for-age is a good indicator of long-term nutritional status Failure to thrive: not growing at the expected rate for several months; dramatically smaller or shorter than other children of same age Potential causes for failure to thrive Physical abnormalities (e.g., heart defects, cleft palate) Infections Intestinal problems Inborn errors of metabolism Nutrition or feeding problems Poverty Lack of parental knowledge Weak sucking ability Poor feeding techniques Mental depression in mother Negative socialization factors Long-term effects of failure to thrive depend on severity and timing; catch-up growth may be possible Growth in height ceases when epiphyses (growth plates at ends of bones) fuse; further growth is no longer possible Girls: 14 - 19 y Boys: 15- 20 y Nutrient Needs General Growth rate has great effect on energy and nutrient needs Peak growth velocity occurs during infancy Calorie and nutrient needs per unit body weight decline from infancy to adulthood, but overall needs increase because body weight increases During puberty, nutrient needs increase and gender differences become obvious; time of greatest total needs for energy and nutrients (except for pregnancy and lactation) Energy Infancy Per unit body weight, infant calorie needs are 2 - 4 times greater than that of adults Large body surface area allows energy loss as heat Newborns require ~ 50 kcal/lb./day From 2 or 3 months through 3 years, infants/children require ~ 40 kcal/lb./day Childhood: from age 3 - 5, children require ~32 kcal/lb./day Adolescence: by age 15, adolescents require ~ 16 kcal/lb./day Protein Infancy: 1.5 g/kg/day (0.7 g/lb.) Excess protein may overtax infants’ immature kidneys, leading to dehydration Childhood Needs are affected by growth and maturation of organs Age 1 - 3: 1.1 g/kg/day (0.5 g/lb.) Older children: 0.95 g/kg/day (0.4 g/lb.) Adolescence Needs are affected by increases in lean body mass Effects of protein malnutrition during growing years Impaired physical development Childhood illness Delayed or stunted growth Death In developed countries, may be due to excessive dilution of infant formula or severely restricted food intake Fat Provides cholesterol, essential fatty acids, and meets high calorie demands Infant: 40 - 55% of kcal, with at least 5 g/day EFAs for eye and nervous system development Dietary recommendations meant to reduce risk of heart disease do not apply to children <2 y Low-fat diets in children <2 y deprive children of nutrients and calories and impair growth Fat intake should be reduced between ages 2 - 5 to 30 - 35% of kcal; replace fat content with nutrient-rich foods Carbohydrate Lactose is primary carbohydrate Starch intake increases to ½ of carbohydrate intake as solid foods are introduced Simple sugar intake should be limited Fiber No recommendations for fiber intake for children 1 quart/day Usually by 4 - 6 months of age Physiological capabilities Kidney function Maturity of digestive tract: absorption of whole proteins until 4 - 5 months of age may predispose child to food allergies Physical ability Control head movements and sit along with support Disappearance of extrusion reflex (tongue thrusting) Ability to make chewing motion Early introduction of solid foods offers no benefit, can be detrimental Overburden immature organs Feeding problems and food dislikes Overconsumption of calories Reduced nutrient density Increased choking risk Sleeping through the night is a developmental milestone and does not depend on amount of food consumed Rate for Introducing Solid Foods Between 6 - 12 months of age, human milk or formula intake decrease as solid food gradually increases; by first birthday, half of calories should come from human milk/formula and half from a variety of solid foods Initial introduction of solid foods: 1 - 2 t mixed with human milk or formula Add 1 food at a time and wait several days before introducing the next food to watch for food sensitivities and allergies Sequence for Introducing Solid Foods Typical progression of solid foods is designed to meet iron and vitamin C needs first, then meet protein needs by 6 - 8 months of age Iron-fortified rice cereal Strained carrots Applesauce Oat cereal Cooked egg yolk Strained chicken Strained peas Strained plums Tips for food choices Cereals and fruit juices marketed for babies have no added salt, sugar, or MSG; iron is in more absorbable form than adult cereals; fortified with vitamin C to enhance iron absorption For prepared baby food, single-food items are usually more nutrient-dense than mixed dinners and desserts Rice cereal is least likely to cause allergies; wheat cereal is most likely Orange juice may be too acidic and not recommended until 1 year of age Delay introduction of commonly allergenic foods (e.g., cow’s milk, wheat, chocolate, egg whites, fish and shellfish, nuts) After 1 year, whole milk is recommended; reduced-fat milk may not meet infant calorie needs without exceeding protein needs and shouldn’t be used until 2 years of age Appearance of teeth allows addition of more texture By 9 months, introduce finger foods and allow self-feeding By 1 year, well-cooked, tender table foods are usually accepted By 1 year, infant should be consuming a variety of foods from all food groups Present new foods for several consecutive days to aid acceptance Avoid honey until 1 year because it may contain Clostridium botulinum spores Weaning from the Breast or Bottle Around 6 months, introduce fruit juices in a spill-proof cup with a wide, flat bottom Babies should be completely weaned from bottle by 18 months to avoid overconsumption of milk or juice and prevent early childhood dental caries Infants should never be put to bed with a bottle to avoid dental caries Learning to Self-Feed Infant must be allowed to practice and experiment with a patient and supportive adult By 1 year, many infants can finger feed and drink from a cup without assistance By 2 years, children can use cups and utensils; good use of fork will occur by age 3 - 4 and knife can be used by age 4 – 5 Clinical Perspective: Potential Nutrition-Related Problems of Infancy Colic: sharp abdominal pain in otherwise healthy infants leading to repeated crying episodes that sometimes last 3+ hours and don’t respond to typical remedies Affects 10 - 30% of all infants Starts at 2 - 6 weeks of age and lasts until 3 months of age Crying episodes tend to occur in late afternoon or early evening, may disrupt nighttime sleep Cause is unknown, generally occurs in absence of physical problems Occurs in temperamental infants May be related to immature nervous system May be due to lack of harmonious interactions between parents and infant Recommendations Check for fatigue, hunger, boredom Holding snugly Pacifier Rhythmic sounds or movements Continue breastfeeding, but consider decreasing maternal consumption of milk products, caffeine, chocolate, and strongly flavored vegetables Consider changing type of formula to soy-based or predigested protein Medications for intestinal gas Parents should try to get rest and set aside time for themselves Gastroesophageal Reflux Frequent spitting up starting before 2 - 3 months of age, usually resolves by 1 year Caused by incomplete closure of lower esophageal sphincter Usually poses no serious medical concerns, but surgery may be required to correct serious cases Milk Allergy Cow’s milk contains > 40 potentially allergenic proteins, only some of which are inactivated by heating True milk allergies develop in 1 - 3% of formula-fed infants, leading to vomiting, diarrhea, bloody stools, constipation, etc. May switch to soy-protein formula, but soy protein allergy may also develop Predigested protein formula may be necessary Usually resolves by 3 years of age Ear Infections (Otitis Media) Carbohydrate-rich drinks may pool in throat and tubes leading to ears, promoting bacterial growth May be painful or result in hearing loss Do not allow child to take a bottle to bed Dental Caries Mouth bacteria metabolize sugars and starch to form acids that erode tooth enamel Often caused by sleeping with bottle Prevalence has decreased due to Increased use of fluoride-containing toothpaste School-based dental care programs Fluoridation of water Professional fluoride treatments Tooth sealants Prevention Brush teeth after eating sticky, high-sugar snacks Chew sugarless gum Diarrhea In the U.S., about 500 infants die each year of dehydration resulting from diarrhea About 210,000 are hospitalized for diarrhea Signs of dehydration Dry mouth or tongue Few or no tears No wet diapers for 3 or more hours Irritability Listlessness Sunken eyes and cheeks Prevention of dehydration Increase fluid intake with diarrhea Use specialized electrolyte-replacements fluids (e.g., Pedialyte) Switching to soy-based, lactose-free formula for a few days will allow intestine to resume lactase production Continue breastfeeding throughout duration of diarrhea Children as Eaters General Preschool years are a good time to start healthy eating and physical activity routines Few children and teens meet MyPlate recommendations Greatest risk for nutrient inadequacy Poor eating habits Vegans Limited resources Nutrition assistance for those with limited resources Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) School Breakfast Program National School Lunch Program Appetites Before and during rapid growth periods, appetites are good During periods of slow growth or plateaus, appetite drops significantly Low or high intakes are a concern if they occur with Fatigue Increased susceptibility to infection Underweight Failure to thrive Obesity Healthy, normal weight children self-regulate food intake to match needs Caregiver practices to avoid Bribery: decreases preference for hurdle food, increases preference for reward, teaches use of food as reward Forcing Teasing Trickery Restriction of child’s food intake to prevent obesity Teaching a child to override hunger and satiety signals or to use food as a reward can lead to future weight problems Parents are responsible for providing appropriate, nutritious, appealing, regular meals and snacks; children are responsible for deciding how much to eat When, What, and How Much to Serve 6 small meals fulfill nutrient needs and moderate blood glucose levels better than 3 large meals per day due to small stomach size Consuming breakfast improves daily intake of several vitamins and minerals, leads to better performance in school and longer attention span Snacks provide 25% of kcal Serving sizes are ~1 T/year of age, depending on appetite MyPlate for children is a useful menu-planning tool Due to reduced appetite, providing nutrient-dense foods is particularly important Over-emphasizing low-fat diets during childhood is linked to eating disorders and “good food, bad food” attitude Children are sensitive to strong tastes and extreme temperatures Children may reject mixed foods Food Preferences Crisp textures Mild flavors Familiar foods Food preferences begin in utero and continue to develop through adolescence Family has profound influence in early years; peers, teachers, and television influence food choices in later childhood and adolescence Positive role models and nutrition education are important for children to develop healthy eating habits Encourage regular family meals Encourage acceptance of new foods by making them look attractive and serving in a social setting with calm, supportive, approving adults who are eating the food 1-bite rule Involving children in food selection and preparation aids acceptance Mealtime Challenges Food jags: demanding same food repeatedly Only present a problem if food is high in sugar, fat, or sodium or if food jag lasts more than a few weeks Serve the food with the knowledge that the jag will pass Refusal to eat Avoid overreacting so that child doesn’t learn to use food refusal to get attention or manipulate a situation Child should remain at table Remove uneaten food Wait until next meal or snack to provide food; hunger is motivation to eat Sudden loss of appetite can signal illness Picky eating Usually an expression of independence Nagging, forcing, or bribing reinforces behaviors Offer a variety of healthy foods and let the child choose what and how much to eat Family tension at mealtime contributes to feeding problems; parents should learn what to expect and set appropriate food-related goals Clinical Perspective: Potential Nutrition-Related Problems of Childhood Constipation Common causes Inadequate fiber Inadequate fluids Excessive milk consumption Not responding promptly to urges to defecate (fear of painful bowel movement) Recommendations Consume adequate fiber (14 g/1000 kcal) Drink plenty of water Limit milk intake to 16 -24 oz./day Stool softeners, laxatives, or enemas may use used under physician guidance Obesity 1/3 of school-age children are overweight in U.S. Diagnosed when child reaches 95th percentile for BMI and physical exam indicates overfat condition Consequences Ridicule, embarrassment, depression Short stature linked to early puberty (females) Cardiovascular disease Type 2 DM Hypertension Premature death High likelihood that childhood obesity will progress to adulthood obesity Factors that contribute to childhood obesity Heredity Environment (e.g., television, computer, or video games should be limited to 14 hours/week) Dietary behaviors (e.g., excessive snacking, over-reliance on fast food, easy availability of high-fat, high-calorie foods) Physical activity behaviors - key contributor Prevention is best approach Offer nutritious diet Provide opportunities for physical activity Treatment Assess physical activity level, encourage more physical activity (60+ minutes of moderate to intense activity per day) Find new ways to relate to foods Stop mindless snacking Limit portions Provide support, admiration, and encouragement for weight control Weight-loss diet is usually not necessary; stored energy can be used for growth Stunted growth Impaired brain development (children under 2 years of age) Micronutrient deficiencies Impaired eating behaviors Strained parent-child relationships If adult height has been achieved, weight loss may be necessary Gradual rate (1 lb./week) Medications or surgery may be indicated Professional supervision Accept diversity in body shape Hyperactivity: distractibility, impulsiveness, disruptive behavior, and overactivity Diet-related causes have been proposed, but scientific evidence is lacking Food allergies Additives - recent well-controlled study shows links between additives and hyperactivity Sugar consumption Megadoses of vitamins will not cure hyperactivity and may cause liver damage or intestinal distress Modifications of Child and Teen Diets to Reduce Future Disease Risk Cardiovascular disease Early cholesterol screening in families with history of CVD or high blood cholesterol Dietary changes: encourage moderation of milk and animal proteins; focus on limiting saturated fat, trans fat, and cholesterol Medications Hypertension Establish habit of moderate salt intake DASH diet Medications Type 2 DM Screening at-risk children every 2 years starting at age 10 or onset of puberty Risk factors include family history, sedentary lifestyle, and obesity Treatment Dietary modification (e.g., low glycemic load) Physical activity Medications Teenage Eating Patterns General Food consumption increases with growth spurt Types and amounts of foods are same as for adults, but teenagers need more calcium-rich foods Problem areas Inadequate fruits and vegetables Excessive cholesterol, sugar, fat, saturated fat, trans fat, protein, and sodium Alcohol consumption Teenage boys have better nutrient intakes because they consume 700 - 1000 more kcal/day than girls Replacing milk with soft drinks compromises bone health AI for calcium for males and females, ages 9 - 18: 1300 mg/day Eating away from home and skipping meals decrease diet quality Snacks account for 25% of total kcal; depending on food choices, snacks can make positive or negative contribution to nutrient intake Strategies to improve teen food choices Provide nutritious foods at home Schedule family meals at least a few times per week Factors Affecting Teens’ Food Choices Emergence of independence and change in lifestyle (e.g., participation in after-school activities) may affect nutrition Body Image Dissatisfaction with appearance is common Boys want to look stronger, more muscular Girls want to look thinner Fear of obesity may lead to fad diets, diet pills, unrealistic and unhealthy weight goals, severe food restriction, and eating disorders Athletics and Physical Performance Teenage athletes may not consume additional calories and nutrients needed to maintain normal growth and maturation to support physical activity Calorie restriction or unbalanced diets may be used to meet weight limits or achieve desired appearance for certain sports Overuse of protein is common among football players and bodybuilders Endurance athletes may practice carbohydrate loading Over-restriction or overemphasis of any nutrient can be detrimental to health Low body fat in females may lead to amenorrhea, which is detrimental to bone health; weight gain and vitamin and mineral supplementation may be needed Substance Use Associated with poor diets, reduced interest in food and eating, and poor nutrition status Alcohol May displace nutritious foods Alter metabolism of nutrients Increase needs for/excretion of nutrients Cocaine Loss of interest in food Weight loss, malnutrition, eating disorders Nicotine Suppresses appetite Associated with poor intake of fiber, vitamins, and minerals Increased needs for vitamin C Marijuana Distorts appetite Encourages snacking on foods that are high in carbohydrates, fat, and calories Helping Teens Eat More Nutritious Foods Focus on short-term benefits For teenage boys, stress importance of nutrition and physical activity for physical development, fitness, vigor, and health For teenage girls, emphasize nutrient-dense foods and enjoyable physical activities for better health and healthy weight Small portions of fatty or sweet foods can complement larger portions of nutrient-dense foods MyPlate is a useful tool for menu planning D. Clinical Perspective: Potential Nutrition-Related Problems of Adolescence Acne Affects 80% of teens; due to oily secretions that block pores Research fails to support link between any dietary factor and acne Megadoses of vitamins or minerals do not cure acne Vitamin A analogs may be prescribed for severe cases, but close supervision is needed to prevent toxicity Avoid pregnancy due to risk of birth defects Teenage Pregnancy Meeting dietary requirements of adolescence and pregnancy is a challenge Pregnant teens may try to hide pregnancy Calorie restriction Lack of prenatal care Lack of education and financial resources complicate pregnancy outcomes Pregnancy within 2 years of menarche poses greatest nutritional risk Physical immaturity Anemia Pregnancy-induced hypertension Spontaneous abortion Premature birth Low birth weight Maternal death Inadequate Nutrition Knowledge Accurate nutrition information is needed to make informed food choices Health habits formed early in life persist into adulthood School-based nutrition education is needed Chapter 18 Nutrition During the Adult Years Overview Chapter 18 covers the changing nutritional needs and concerns of adulthood, which spans from the end of adolescence until death. The differences between usual aging and successful aging are discussed. Adults typically over-consume protein and fat and under-consume fluids and carbohydrates, especially those that provide fiber. Although calorie needs decrease throughout adulthood, nutrient-dense foods are needed to maintain proper function of all body systems and decrease risk of chronic diseases and other common ailments of aging. Nutrients of particular concern during adulthood include calcium, vitamin D, folate, vitamin B-6, vitamin B-12, iron, zinc, magnesium, vitamin E, and carotenoids. Nutrition assistance programs designed to help older adults maintain nutritional status are outlined. The Medical Perspectives section presents information on complementary and alternative medicine. Learning Objectives Describe the hypotheses about the causes of aging. Discuss the factors that affect the rate of aging. Explain how the basic concepts that underlie the Dietary Guidelines for Americans relate to adult health. Compare the dietary intake of adults with the current recommendations. Discuss the effects of physical, physiological, psychosocial, and economic factors on the food intake and nutrient needs of adults. Describe community nutrition services for older persons. Identify nutrition-related health issues of the adult years and describe the prevention and treatment of these health problems. List the potential benefits and risks associated with the use of complementary and alternative medicine practices. Teaching Strategies, Activities, Demonstrations, and Assignments 1. Assign students the Take Action activity, “Stop the Clock! Are You Aging Healthfully?” 2. Assign students the Take Action activity, “Helping Older Adults Eat Better.” It is a case study of an elderly person with nutritional status and outlook problems. Have them bring it to class completed and use it as a springboard for class discussion about helping elderly people achieve good nutritional status. 2. Ask a nutrition professional from the local branch of the Federal Office of Aging to give a guest lecture in your class about the problem of nutrition and aging. 3. If possible, plan for students to visit an elderly feeding program and join the seniors for lunch. Ask them to share their observations of nutritional quality of the diet, and acceptance of the meal by the participants and other activities associated with the meal program. Many such programs welcome guests and eagerly seek volunteers. 4. Ask students to plan a menu for one day for a man and woman who is 70 years of age. It should meet their nutritional needs and the midpoint of the RDA range for kcals for their age. Assign students the Real Age test at http://www.sharecare.com/static/realage-test. Have them bring their results to class. Discuss the lifestyle and nutritional recommendations offered by the site. Ask whether the students checked out the site’s Scientific Advisory Board to determine the qualifications of those providing the recommendations. For those students who were assigned a diet analysis project at the beginning of the course, ask them to complete a new diet analysis. Have them write a paper on the nutritional knowledge they have gained since the start of the course and how they have implemented it in their lives. What changes have they made during the term? What has been the impact on their food choices and meeting their nutritional goals? Divide the class into groups and assign a disease to each group. Based upon their research, have each group design a screening questionnaire for that disease. Have the students present their list of questions and their rationale for choosing them. Using their diet analysis software, have students create a food list called “One Perfect Day.” Ask them to use their own food preferences to create a single day diet that most closely fulfills their personal RDAs. Lecture Outline Physical and Physiological Changes during Adulthood General Adulthood spans from completion of physical growth at the end of adolescence through death Nutrients are used for body maintenance rather than physical growth Food and Nutrition Board divides adulthood into four stages Young adulthood: 19 - 30: body systems operate at peak efficiency 31 - 50: rate of cell breakdown slowly begins to exceed rate of cell renewal, leading to gradual decline in organ size and efficiency Middle adulthood: 51 - 70 Older adulthood: 70+ Aging: time-dependent physical and physiological changes in body structure and function that occur normally and progressively throughout adulthood as humans mature and become older Reserve capacity: extent to which an organ can preserve normal function despite decreasing cell number or activity Decreased capacity causes problems when severe demands are placed on the body Aging is likely the sum of automatic cellular changes, lifestyle practices, and environmental influences Proposed causes of aging (see Table 18-1) Errors in DNA Stiffening of connective tissue Oxidative damage by free radicals Hormone function changes Immune system insufficiency Development of autoimmunity Glycosylation of proteins Programmed cell death Excess energy intake Some changes of aging are inevitable, but many degenerative age-related changes can be minimized, prevented, and/or reversed by healthy lifestyle practices and avoiding adverse environmental factors Usual and Successful Aging Usual aging: expected age-related physical and physiological changes, many of which are actually the results of unhealthy lifestyle choices, adverse environmental exposures, and chronic diseases Increasing body fatness Decreasing lean mass Rising blood pressure Declining bone mass Increasingly poor health Successful aging: physical and physiological function declines that occur only because of advancing years, not due to lifestyle choices, environmental exposures, or chronic diseases Compression of morbidity: maximizing healthy years and minimizing illness; delayed onset of chronic diseases Factors Affecting the Rate of Aging Heredity Longevity is somewhat genetically determined Females live longer than males Thrifty metabolism Requires fewer calories for metabolic processes Stores fat more easily Leads to obesity and chronic disease with overabundance of food and sedentary lifestyle Rate of HDL cholesterol production Genetic ability to produce abundant HDL may decrease risk of CVD Reduced ability to produce HDL leads to premature death and shorter life Lifestyle and environment can modify expression of genetic potential Lifestyle Food choices Exercise patterns Substance use Environment Income Education level Health care Shelter Psychosocial factors Nutrient Needs During Adulthood Dietary Guidelines for Americans Consume a variety of nutrient-dense foods and beverages that result in a diet low in saturated and trans fat, cholesterol, added sugars, salt, and alcohol (if used). Maintain body weight in a healthy range by controlling energy intake, increasing physical activity and reducing time spent in sedentary behaviors Build healthy eating patterns that meet nutrient needs and reduce the risk of foodborne illness Benefits of good nutrition Delay onset of certain diseases Improves management of existing diseases Speedy recovery from illnesses Increases mental, physical, and social well-being Decreases need for and length of hospitalization Common dietary excesses and inadequacies Excess calories, fat, sodium, alcohol Inadequate vitamins D and E, folate, magnesium, calcium, zinc, and fiber (and iron for women before menopause) DETERMINE Checklist (Nutrition Screening Initiative) Disease Eating poorly Tooth loss or mouth pain Economic hardship Reduced social contact and interaction Multiple medications Involuntary weight loss or gain Need for assistance with self-care Elder at advanced age Defining Nutrient Needs Calories After age 30, calorie needs of physically inactive adults fall throughout adulthood due to gradual decline in basal metabolism Exercise can halt, slow, or reverse reductions in lean body mass Protein Adult protein intake exceeds recommendations Consuming protein slightly in excess of RDA may help preserve muscle and bone mass Risk for inadequate protein intake Limited food budget Chewing difficulties Lactose intolerance Excess protein intake contributes to energy storage and may accelerate kidney function decline Fat Adult fat intake exceeds current recommendations Reducing fat intake cuts risk for overweight, obesity, and chronic disease Seek more nutrient-dense foods to meet nutrient needs Carbohydrates Adult carbohydrate intake may be lower than recommendations Emphasize complex carbohydrates and fiber; decrease simple carbohydrates Meet nutrient needs Regulate blood glucose Reduce risk of colon cancer and heart disease Lower blood cholesterol Avoid constipation Typical fiber intake is ½ of recommendation Water Many older adults consume inadequate fluids Causes of low fluid intake in older adults Decreased sense of thirst Chronic disease Conscious reduction to reduce frequency of urination Fluid restrictions due to medications, ostomy, or kidney disease Consequences of inadequate fluid intake Mild dehydration Electrolyte imbalances Disorientation and mental confusion Constipation, fecal impaction Death Minerals and Vitamins Calcium and Vitamin D Tend to be low for all adults, but especially problematic for adults over age 50 Inadequate intake Reduced absorption of calcium Reduced synthesis of vitamin D by the skin Decreased ability of kidneys to convert vitamin D to active hormone Contributes to development of osteoporosis Food sources of vitamin D are limited; major sources (e.g., fatty fish, fortified milk) are not widely consumed by older adults Lactose intolerance prevents consumption of calcium-rich dairy products among many older adults, but consuming small amounts of milk at mealtime is usually well tolerated To meet calcium needs, older adults should consume calcium-fortified foods, cheese, yogurt, fish with bones, dark green leafy vegetables 10 - 15 minutes per day of sunlight can improve vitamin D status Iron Iron deficiency anemia is most common among women during reproductive years Anemia may also result from GI tract injuries that cause bleeding (e.g., ulcers, hemorrhoids) and use of medicines that cause blood loss (e.g., aspirin) Iron absorption may be impaired due to atrophic gastritis, which decreases HCl production Zinc Suboptimal dietary intake Zinc absorption declines as stomach acid production decreases Leads to loss of sense of taste, mental lethargy, and delayed wound healing Magnesium Suboptimal dietary intake Leads to loss of bone strength, muscular weakness, mental confusion, abnormal heart rhythm, Linked to CVD, osteoporosis, and DM Dietary sources are preferred; supplements can cause diarrhea Folate and Vitamins B-6 and B-12 For women during childbearing years, adequate folate status decreases risk for NTDs In middle and older adulthood, adequate folate, B-6, and B-12 are required to metabolize homocysteine; hyperhomocysteinemia is associated with CVD, stroke, bone fracture, and neurological decline Vitamin B-12 deficiency may exist despite adequate dietary intake due to poor absorption (decreased stomach production of acid and intrinsic factor) Adults age 51+ likely need fortified foods and supplements containing synthetic B-12 Vitamin E Suboptimal dietary intake Reduces antioxidant capabilities; increased oxidative damage may lead to chronic diseases, cataracts, and speed the aging process Carotenoids Lutein and zeaxanthin protect against cataracts and age-related macular degeneration Diets high in fruits and vegetables supply carotenoids and other beneficial phytochemicals Factors Influencing Food Intake and Nutrient Needs Physical and Physiological Factors (see Table 18-2) Body Composition Sarcopenia: gradual, steady decline in lean body mass decreases basal metabolic rate, muscle strength, and energy needs Decline in body water Increase in fatty tissue Redistribution of body fat from limbs to torso increases risk for chronic diseases Physically active lifestyle (including aerobic exercises, strength training, and balance exercises) can maintain muscle mass Weight loss with aging increases risk of malnutrition and death Skeletal System Slow, steady loss of bone minerals (especially after menopause in women) may lead to osteoporosis Osteoporosis limits ability to shop and prepare food, thereby complicating nutritional status Practices that preserve bone health Adequate vitamin D, calcium, and protein intake Moderate alcohol intake Avoidance of smoking Engaging in weight-bearing activity Medications Cardiovascular System Gradual decrease in delivery of oxygen and nutrients to body cells and removal of metabolic wastes Hypertension Practices that preserve cardiovascular function Remain physically active Avoid smoking Consume low-fat, nutrient-rich diet Moderate sodium intake Respiratory System Decreased lung capacity limits body function, physical activity, eating Emphysema and lung cancer Practices that preserve respiratory function Avoid smoking Consume antioxidant-rich diet Physical activity Digestive System Diminished chewing ability (e.g., gum disease, tooth loss) Declines in digestion and absorption due to diminished HCl, intrinsic factor, and enzymes Functions of accessory organs decline Decreased ability of liver to metabolize alcohol and drugs; increased risk of vitamin or mineral toxicity Gallbladder disease interferes with fat digestion Declining pancreatic function may decrease digestion of nutrients and complicate blood glucose control Slowed motility leads to constipation and hemorrhoids Practices that preserve digestive function Consume adequate fiber and fluids Physical activity Possible use of fiber supplements, stool softener, or laxative Avoid vitamin and mineral megadoses Low-fat diet Maintain healthy weight Routine dental hygiene and care Serve soft, easy-to-chew foods; allow extra time for chewing and swallowing Urinary System Decreased kidney function impairs filtration of metabolic wastes and ability to concentrate urine Decreased ability to convert vitamin D to active form Weakening of muscles that control urination Practices that preserve urinary system function Avoid excess protein intake Nervous System Decreased sensory perceptions Slowed reaction times Impaired coordination, reasoning, and memory Nervous system changes lead to social isolation and impair ability to shop for, prepare, and consume nutrient-dense foods Practices to preserve nervous system function Consume diet rich in fruits and vegetables to reduce risk of macular degeneration and cataracts Immune System Increased susceptibility to infection and disease Practices that preserve immune function Consume adequate protein, folate, vitamin A, vitamin D, vitamin E, iron, and zinc Avoid obesity Avoid excessive fat, iron, and zinc intakes Endocrine System Glucose intolerance or diabetes Slowed metabolic rate due to declines in thyroid hormone Loss of lean body mass and thinning skin due to declines in growth hormone Practices that preserve endocrine function Maintain healthy weight Exercise regularly Consume low-fat, high-fiber, low-GI diet Reproductive System Females: declines in estrogen after menopause Iron needs drop Increased risk of CVD and osteoporosis Males: slow declines in testosterone after age 60 Decreased lean body mass diminishes calorie needs Chronic Disease Prevalence of obesity, heart disease, osteoporosis, cancer, hypertension, and DM increase 8 of 10 elderly adults have at least 1 chronic disease Half of older adults have at least 2 chronic diseases Impaired physical function may decrease ability to shop for, prepare, and consume nutrient-dense foods Chronic diseases may affect nutrient and calorie needs and utilization Cancer boosts nutrient and calorie needs Hypertension may require lower sodium intake Diabetes alters glucose utilization Kidney disease affects retention of glucose, amino acids, and vitamin C Medications Half of older adults practice polypharmacy Half of older adults use daily supplements Effects of medications and supplements may be exaggerated and more persistent among older adults Some medications adversely affect nutrition status Depress taste and smell Cause anorexia Aspirin increases risk of stomach bleeding, which may elevate iron needs Antibiotics may deplete vitamin K Diuretics and laxatives may cause excessive excretion of water and minerals High doses of minerals affect absorption of other minerals Folate supplements can mask vitamin B-12 deficiencies Some nutrients interact with medications Vitamin K alters action of oral anticoagulants Aged cheese can affect action of hypertension and depression medications Grapefruit can interfere with tranquilizers and cholesterol-lowering medications Psychosocial Factors Apathy and depression may lead to changes in appetite and food intake Depression is diagnosed in about 15% of older adults Social isolation diminishes food intake Economic Factors Unemployment, underemployment, retirement, or other factors that limit income restrict ability to obtain nutritious foods Nutrition assistance programs are available Table 18-5 presents guidelines for healthful eating in later years Eat regularly Eat with others Eat in well-lit or sunny area; serve attractive meals; vary flavors, colors, shapes, textures, and smells Exercise before eating to stimulate appetite Arrange kitchen for easy food preparation and cleanup Use labor-saving equipment and foods Try new things Keep easy-to-prepare foods on hand Share cooking responsibilities with neighbor Add dry milk to increase nutrients in mixed dishes Cook large amounts and freeze small portions Chop, grind, or blend hard-to-chew foods; serve soft foods Cut foods ahead of time; obtain specialized utensils Use community resources to obtain meals Buy only what can be used Break family-size packages into smaller portions Buy produce at varied stages of ripeness Meal replacement bars or formulas Stay physically active Nutrition Assistance Programs USDA and U.S. Administration of Aging administer several assistance programs Commodity Supplemented Food Program distributes surplus agricultural products to low-income households at no charge Supplemental Nutrition Assistance Program (formerly Food Stamp Program) provides nutrition education and electronic benefit transfer cards (like debit cards) to purchase foods, plants, seeds, some meals at shelters and authorized restaurants Child and Adult Care Food Program provides nutritious meals and snacks to low-income children in child-care centers or emergency shelter or adults in non-residential adult day-care centers Senior Farmers’ Market Nutrition Program provides coupons for fresh fruits, vegetables, and herbs at farmers’ markets, roadside stands, and other community-support agriculture programs U.S. Administration on Aging administers Older Americans Act, which helps older adults maintain independence Adult day care Senior center activities Transportation Information Counseling services Health and physical activity programs In-home care Elderly Nutrition Program provides nutrition services Congregate Meal Program Home Delivered Meal Program Shopping assistance Counseling Nutrition education Referrals to social, rehabilitative, and transportation services Nutrition-Related Health Issues of the Adult Years Conditions discussed in previous chapters Atherosclerosis Cancer Constipation Diabetes Diverticular disease Heartburn Hypertension Obesity Osteoporosis Alcohol Use Consequences of alcohol use and abuse are magnified with advancing age Faster intoxication due to slower metabolism of alcohol and decreased body water Interactions with medications Increased risk of stroke Aggravated hypertension Adults over age 65 should limit alcohol intake to 1 drink/day Alcohol abuse May arise from loneliness, social isolation, death of spouse Symptoms may be disregarded as part of normal aging Trembling hands Sleep problems Memory loss Unsteady gait Slowed Restoration of Homeostasis Slower kidney function Slower metabolism of alcohol, drugs, and supplements by liver Increases vulnerability to illness and death Prudent lifestyle choices to preserve optimal body system function Prophylactic measures (e.g., flu shots) Avoid excessive protein intake Get prompt medical attention for illness or injury Avoid stress Alzheimer’s Disease Irreversible, abnormal, progressive deterioration of the brain that leads to loss of memory, reasoning, and comprehension 10 warning signs Recent memory loss that affects job performance Difficulty performing familiar tasks Problems with language Disorientation to time and place Faulty or decreased judgment Problems with abstract thinking Tendency to misplace things Changes in mood or behavior Changes in personality Loss of initiative Potential causes Altered cell development or protein production in brain Strokes Altered lipoprotein composition Obesity DM Hypertension High cholesterol Oxidative stress Prevention Maintain brain activity through lifelong learning Diet rich in berries and olive oil Exercise Getting enough antioxidant nutrients, vitamins C and E, helps protect against free radicals Adequate folate, B-6, and B-12 to decrease homocysteine levels, which are a risk factor for Alzheimer’s disease Diets rich in essential fatty acids and low in saturated and trans fats reduce risk of Alzheimer’s disease Disease complicates nutritional status due to poor food intake Dietary recommendations Monitor weight Serve omega-3 rich fish twice per week Avoid choking hazards Regular physical activity Arthritis Disease that causes degeneration and roughening of cartilage that covers and cushions joints and/or formation of calcium deposits (spurs), leading to inflamed and painful joints Osteoarthritis is leading cause of disability among older adults Rheumatoid arthritis is more prevalent in younger adults No special diet, food, or nutrient has been proven to prevent, relieve, or cure arthritis Maintenance of healthy weight offers relief Clinical Perspective: Complementary Health Approaches CAM: any medical or health-care system, practice, or product not presently part of conventional medicine Biologically based practices: using pharmacological agents, foods, diets, vitamins, herbs to prevent disease Mind-body interventions: using mind techniques, creative therapies, patient support groups, medication, yoga, and/or prayer to enhance physical health Energy medicine: using energy fields or “biofields” to promote healing Manipulative and body-based practices: using hands to promote healing Alternative systems of medical practice: using Ayurveda, naturopathy, homeopathy, or traditional medicines from other cultures Although some are well accepted (e.g., chiropractic medicine, acupuncture), many have not been tested in clinical trials or are ineffective Reasons for use Perception that natural therapy is gentler than conventional medicine Conventional medicine was not effective or caused many side effects Conventional medicine offers no cure Appear to relieve symptoms in some people (may be placebo effect, natural progression of disease, or remission) Rational approach Keep diary of symptoms Follow one therapy at a time Consult physician before discontinuing prescribed medical treatment Work with experienced practitioners Enroll in clinical trial investigating usefulness of CAM therapies Report adverse effects Cautions with CAM Testimonials of friends and relatives do not substitute for scientific proof of safety and effectiveness U.S. government provides little regulation of herbal products Fraudulent claims for diet- and health-related remedies are widespread If it sounds too good to be true, it probably is A Closer Look at Herbal Therapy Should be used with caution, preferably under physician supervision Some are harmless, some are toxic, some may be effective Interactions between alternative therapies and pharmaceuticals are possible and can be drastic Mislabeling, adulteration, or varied potency are possible Herbal products should be avoided by some groups Pregnant or nursing women Anyone with chronic diseases Children under age 2 Examples (see Table 18-6) Black cohosh may reduce postmenopausal symptoms Coenzyme Q-10 may reduce oxidative stress in people with chronic conditions Echinacea may stimulate immune system; studies show little or no effect Feverfew may reduce pain and frequency of migraines Garlic may have antibiotic, cholesterol-lowering, or blood pressure-lowering properties Ginger may prevent motion sickness and nausea related to surgery and pregnancy Gingko biloba may increase circulation, particularly to brain and lower extremities; evidence is very weak Ginseng may decrease weakness and fatigue and increase resistance to stress; studies do not confirm benefit Glucosamine may decrease joint inflammation associated with osteoarthritis, but recent large clinical trial showed no benefit Milk thistle may protect liver St. John’s wort has mild antidepressant effect that may work by inhibiting monoamine oxidase, which destroys serotonin, epinephrine, and dopamine Saw palmetto may reduce symptoms of enlarged prostate gland; some studies show moderate effectiveness, others show no benefit Valerian: may alleviate restlessness and other sleeping disorders DHEA converts to estrogen and testosterone; taken to aid weight loss or treat depression, but benefits of supplementation are unproven Growth hormone stimulates cell synthesis; may be useful with GH deficiencies Melatonin may aid sleep and reduce jet lag Testosterone affects muscle mass and strength, can reduce menopausal symptoms in women and possibly depression in older men Instructor Manual for Wardlaw's Perspectives in Nutrition Carol Byrd-Bredbenner, Gaile Moe , Jacqueline Berning , Danita Kelley 9780078021411
