Chapter 5: Nutrition Across the Lifespan PDF

MARIANO MARCOS STATE UNIVERSITY College of Health Sciences CHAPTER 5: NUTRITION ACROSS THE LIFESPAN Nutrient needs vary greatly throughout the various stages of life. Assessing and addressing a woman’s nutritional status before she conceives makes it far easier t...

MARIANO MARCOS STATE UNIVERSITY College of Health Sciences CHAPTER 5: NUTRITION ACROSS THE LIFESPAN Nutrient needs vary greatly throughout the various stages of life. Assessing and addressing a woman’s nutritional status before she conceives makes it far easier to encourage optimal birth outcomes than trying to intervene after she is already pregnant. Good nutrition during the 38 to 40 weeks of a normal pregnancy is essential for both mother and child. Achieving adequate nutrient status during infancy, promoting healthy eating habits in toddlers, and encouraging balanced food intakes and proper weight management throughout childhood and adolescence all set the stage for the best possible transition into a healthy adulthood. This chapter will cover the unique nutrient needs specific to each stage of life, from preconception to pregnancy, breastfeeding, infant weaning, childhood feeding practices, school-age child, adolescent, and older adult. This chapter is divided into six (6) lessons. Overall, the lessons have a time allotment of two (2) hours only. Lesson 1: NUTRITION IN PREGNANCY AND LACTATION Lesson 2: NUTRITION IN INFANCY Lesson 3: NUTRITION IN CHILDHOOD Lesson 4: NUTRITION IN ADOLESCENSE Lesson 5: NUTRITION IN THE ADULT YEARS Lesson 6: NUTRITION IN AGING NCM 105: NUTRITION AND DIET THERAPY 1  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Lesson1 NUTRITION IN PREGNANCY AND LACTATION Nutrient needs typically increase more during pregnancy than during any other stage in a woman’s adult life. Additional nutrients are required during gestation for development of the fetus as well as for growth of maternal tissues that support fetal development. The materials required for this rapid growth and development depend on supply from the maternal diet. However, because of the differing roles nutrients play in tissue development and growth as well as nutrient-specific changes in maternal homeostasis during pregnancy, nutrient requirements do not increase uniformly. Changes in the efficiency of absorption from the gastrointestinal tract and excretion by the renal system, as well as changes in maternal storage or tissue reserve, are examples of homeostatic mechanisms that must be considered in establishing nutrient requirements during gestation. Because the demand for some nutrients is great relative to others, care must be taken in selecting the optimal diet during pregnancy. Studies have shown a relationship between the mother’s diet and the health of the baby at birth. It is also thought that the woman who consumed a nutritious diet before pregnancy is more apt to bear a healthy infant than one who did not. Malnutrition of the mother is believed to cause decreased growth and mental retardation in the fetus. Low-birth- weight infants (less than 5.5 pounds) have a higher mortality (death) rate than those of normal birth weight. Learning Outcomes: By the end of the lesson, you must have: 1. Identified nutritional needs during pregnancy and lactation. 2. Discussed lactation management techniques. 3. Modified the normal diet to meet the needs of pregnant and lactating women. 4. Explained the physiological reasons for adjusting nutrient requirements during pregnancy. Warm-up Activity: Let’s see how broad is your knowledge prior to the start of your lesson. For three (3) minutes, try to answer the questions. After that, try to compare your answers with your classmates through messaging them. Let’s go! 1. When a woman becomes pregnant, is there a necessary to increase the food intake of the woman? If yes, why? If no, why? NCM 105: NUTRITION AND DIET THERAPY 2 2. If you answered yes, enumerate some dietary guidelines necessary during pregnancy. If you’re done answering questions, try to compare your answers with your classmates by messaging them.  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Learning Inputs: A. Prenatal Risk Assessment Women who are interested in becoming pregnant need a “preconception risk assessment” (March of Dimes, 2009). They should be aware of their personal genetic biomarkers that could cause problems with infertility, pregnancy, childbirth, or chronic diseases. Prenatal Risk Assessments and Indicators of Potentially Poor Outcomes Pre-  Adolescence (poor eating habits, greater needs for pregnanc growth of teen and fetus). y  History of three or more pregnancies in past 2 years, especially miscarriages  History of poor obstetrical/fetal performance.  Overweight and obesity, which can cause a higher risk for gestational diabetes, preeclampsia, eclampsia,  C-section, and/or delivery of infant with macrosomia. Pre-  Economic deprivation. pregnanc  Food faddist; smoker; user of drugs/alcohol; practice of y or pica with related iron or zinc deficiencies; anorexia During nervosa or bulimia Pregnanc  Modified diet for chronic systemic diseases, such as y diabetes, celiac disease, PKU.  Prepartum weight of less than 85% or more than 120% of desirable BMI for height and age; these may reflect inability to attain proper weight or poor dietary habits.  Deficient Hgb (_11 g) or hematocrit (Hct) (_33%) with medical diagnosis of anemia.  Weight loss during PG or gain _2 lb/month in the last two trimesters; dehydration; hyperemesis.  Risk of toxemia (2-lb weight gain per week or more).  Poorly managed vegetarian diet, especially vegan diet without supplementation.  Poor nutrient or energy intakes over the duration of the pregnancy.  Poor intake of magnesium, zinc, calcium, iron, folate, vitamins A and C, and other key nutrients. NCM 105: NUTRITION AND DIET THERAPY 3  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences B. Nutritional Requirements During Pregnancy Weight gain during pregnancy is natural and necessary for the infant to develop normally and the mother to retain her health. During the second and third trimesters of pregnancy, the mother needs more kilocalories for two general reasons: 1. to supply the increased fuel demanded by the metabolic workload for both the mother and the fetus; and 2. to spare protein for the added tissue building requirements. Caloric intake: 300 kcal/day Energy requirements: 1st trimester: same as non-pregnant women 2nd trimester: 340 kcal and 3rd trimester: 452 kcal per day For these reasons, the mother must consider the nutrient and energy density of the food in her diet. No one should lose weight during pregnancy, because it could cause nutrient deficiencies for both mother and infant. On average, a pregnant adult requires no additional calories during the first trimester of pregnancy and only an additional 300 calories a day during the second and third trimesters. NCM 105: NUTRITION AND DIET THERAPY 4  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Table 1. Recommendations for Pregnant Women C. Nutritional Interventions During Pregnancy  Maintain adequate gestational duration; avoid preterm delivery.  Provide adequate amount of weight gain during the pregnancy; prevent delivery of LBW infants. o Underweight women (BMI _18.5) should gain 28–40 lb o Normal weight women (BMI _ 19–24.9) should gain 25–35 lb total o Overweight women (BMI _ 25–29.9) should gain 15–25 lb o Obese women (BMI _30) should gain 11–20 l  as obesity is a risk for undesirable consequences, including neural tube defects  Encourage proper rate of weight gain: o 2–4 lb first trimester o 10–11 lb second trimester o 12–13 lb third trimester o More weight should be gained if patient is below ideal weight range before pregnancy, especially in younger women. Adolescents are at high risk of gaining an excessive amount of weight during pregnancy and should be closely monitored.  Provide additional nutrients and energy (net cost of pregnancy varies from 20,000–80,000 kcal total). Women carrying more than one fetus must add extra kilocalories to support multiple births.  Prevent or correct hypoglycemia and ketosis.  Provide adequate amino acids to meet fetal and placental growth. Approximately 950 g of protein are synthesized for the fetus and placenta. Low protein intake may lead to a smaller infant head circumference.  Promote development of an adequate fetal immune system.  Prevent or correct deficiencies of iron, which are common in 50– 75% of pregnancies. Iron deficiency may cause low infant birth weight and premature birth.  Folate deficiency and elevated homocysteine levels may lead to miscarriage, club foot, structural heart disease, anencephaly and neural tube defects. A woman with a history of spontaneous NCM 105: NUTRITION AND DIET THERAPY 5  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences abortion in her immediate prior pregnancy and short interpregnancy interval is especially vulnerable. L-methylfolate is the natural, active form of folate used for DNA reproduction and regulation of homocysteine levels. Women with altered genetic alleles may not have sufficient methyl-tetrahydrofolate (MTHFR) enzymes to use folic acid properly. Vitamins B6 and B12 will also be needed if homocysteine levels are elevated.  Vitamin A deficiency is strongly associated with depressed immune system and higher morbidity and mortality due to infectious diseases such as measles, diarrhea, respiratory infections. On the other hand, doses of 10,000–30,000 IU vitamin A/D may cause birth defects.  Avoid zinc, vitamin D, or calcium deficiencies.  Supply sufficient iodine (250 ug) to prevent cretinism with mental and physical retardation. Systematic provision of iodine supplementation is recommended, especially if women are cutting back on intake of iodized salt  Limit caffeinated beverage intake to two cups daily.  Avoid alcohol. Mothers who drink relatively high levels of alcohol around the time of conception increase the risk for orofacial clefts and spina bifida.  Support the individual patient; pregnant women who are fatigued, stressed, and anxious tend to consume more macronutrients and decreased amounts of micronutrient.  Develop or improve good eating habits to prevent or delay onset of chronic health problems postnatally.  Discuss the importance of a high-quality prenatal diet. Fetal under-nutrition can predispose to hypercholesterolemia and program food preferences that are more atherogenic  Women should drink plenty of fluids to remain adequately hydrated.  Multiple gestation creates new challenges and magnified nutritional requirements. There are more risks for adverse outcomes, including diabetes, hypertension, eclampsia, delivery of a premature or LBW infant. For twins, weight gain should reflect the period of gestation and prepartum BMI; 35–45 lb is often recommended with twins, and 50 lb overall is recommended for triplets.  Monitor BP and blood glucose regularly to prevent or to identify complications such as preeclampsia or gestational diabetes. NCM 105: NUTRITION AND DIET THERAPY 6  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences  Monitor or treat other complications, such as nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum. D. Nutritional Requirements During Lactation Breastfeeding should be supported and encouraged because of its immunological, physiological, economic, social, and hygienic effects on mother and infant. Exclusive breastfeeding for the first 6 months of life provides the best form of nutrition. Because maternal intake and breastfeeding practices vary over the duration of lactation, assess regularly and determine whether or not the infant needs supplemental foods or nutrients. Breastfeeding is an anabolic state, requiring extra energy. Table 2. Recommendations for Lactation E. Nutritional Interventions During Lactation  Support adequate lactation (usual secretion, 750–800 mL/d). Human milk provides 67 kcal/dL. Good energy intake improves milk production, especially in undernourished women. Breast milk can meet nutrient needs during the first 6 months, with possible exception of vitamin D and iron in certain populations.  Exclusive breastfeeding for 6 months has many nutritional benefits. Have the mother continue breastfeeding for up to 1 year when possible. Exclusive breastfeeding should be encouraged for at least 4–6 months in infants at risk of atopy. NCM 105: NUTRITION AND DIET THERAPY 7  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences  Decrease nutritional risks from use of alcohol, stimulants, and medications while mother is breastfeeding. Alcohol intake inhibits the letdown reflex from oxytocin. Discourage excessive use of stimulants, including caffeine from coffee (limit to 2 cups daily) and from tea, colas, and chocolate.  Omit known food allergens while breastfeeding if infant shows signs of colic. Eliminate cow’s milk, eggs, peanuts, tree nuts, wheat, soy, and fish, especially if members of the immediate family have allergies.  Promote adequate infant growth and development, including bone mineralization. Lactation increases the normal daily loss of calcium for the mother, yet is generally beneficial for protecting bone health.  Normalize body composition gradually so that the mother returns to ideal weight. Promote gradual weight loss even in obese women. Weight loss by the mother of 0.5 kg per week after delivery does not affect the growth of breastfed infants.  Support brain health and visual acuity by including fatty acids in the mother’s diet. Both EPA and DHA should be included.  “Best practice” counseling includes one prenatal and one postpartum home contact and telephone consultation by a lactation consultant. Explain them composition of breast milk, the benefits of breastfeeding, nipple care, and what to do during illness or infection.  Self-esteem is crucial. Help mom believe that she can do it; give positive feedback and help her handle negative comments from others. Promotion of self-efficacy is useful. To prevent early discontinuation, lay support (peer counseling) is effective.  Help mom address barriers, such as short maternity leave, lack of private places to pump, coworker comments, minor health barriers, lack of support from doctor or nurses, and old wives’ tales (e.g., breastfeeding spoils the baby, restrictive diet).  Women with delayed onset of lactation need additional support during the first week postpartum; recommend frequent nursing.  To ensure baby receives enough milk, mom should nurse at least eight times in each 24-hour period, no longer than one NCM 105: NUTRITION AND DIET THERAPY 8  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences hour at a time. Baby should be able to rest for about 2 hours between feedings.  Explain the meaning of a balanced diet. Stress food sources of nutrients often limited in their diets: calcium, zinc, folate, and vitamins E, D, and B6.  Explain the use of birth control pills: High estrogen-types are not recommended as they can decrease milk supply. A progestin-only pill is usually recommended by a physician. Activity 1. Study the sample nutrition care process specific to pregnancy and lactation. 1. Rapid Weight Gain in Pregnancy Assessment Data: Dietary history reflects high-caloric food intake; patient statements reflect misinformation; weights and rate of weight gain exceed recommended rate. Nutrition Diagnosis (PES): Excessive energy intake related to misinformation about nutrition needs during pregnancy as evidenced by dietary recall showing daily intake of high-calorie foods, 3-lb body weight gain per week during the second trimester, and 20-lb weight gain by the middle of the second trimester. Intervention: Education on food and nutrient needs during pregnancy. Referral to Women-Infants-Children Program (WIC) if eligible financially and medically. Monitoring and Evaluation: Monthly appointment; include diet history and rate/amount of weight gain. 2. Harmful Beliefs about Food and Nutrition Assessment Data: Food records; signs of infant GI distress or excessive sleep. Nutrition Diagnosis (PES): Harmful beliefs/attitudes about food or nutrition-related topics related to consumption of 4 beers daily while breastfeeding as evidenced by food diary, discussion with mom about “beer making more breastmilk,” and reports that the infant is lethargic during daytime. NCM 105: NUTRITION AND DIET THERAPY 9  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Intervention: Education about appropriate dietary and substance intake for pregnancy. Counseling about dangers of consuming alcohol. Monitoring and Evaluation: Omission of alcohol intake while breastfeeding. Infant weight and infant growth charts; reports about infant sleep and GI patterns. Wrap-up Activity: A pregnant woman is most likely to remain healthy and bear a healthy infant if she follows a well-balanced diet. Research has shown that maternal nutrition can affect the subsequent mental and physical health of the child. Anemia and PIH are two conditions that can be caused by inadequate nutrition. Caloric and most nutrient requirements increase for pregnant women (especially adolescents) and women who are breastfeeding. The average weight gain during pregnancy is 25 to 35 pounds. After learning about the nutrition during pregnancy and lactation, discuss “A pregnant woman must eat for two.” Why is it especially important for a pregnant woman to have a highly nutritious diet? Post-Assessment: A quiz will be uploaded in the mVLE after the discussion. References: Caudal, M.C. (2008). Basic Nutrition and Diet Therapy: Textbook for Nursing Students Revised ed. C&E Publishing, Inc. Escott-Stump, Sylvia. (2008) Nutrition and diagnosis-related care /Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins, Williams, S. R. (2001). Basic nutrition and diet therapy. St. Louis: Mosby. Lesson 2 NUTRITION IN INFANCY Growth is rapid during the first year of life, with the rate tapering off somewhat during the latter half of the year. Most infants more than double their birth weight by the time they are 6 months old, and they triple it by the time they reach about 12 to 15 months of age. Growth in length is not quite as rapid, but infants generally increase their birth length by 50% during the first year and double it by 4 years of age. NCM 105: NUTRITION AND DIET THERAPY 10  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Learning Outcomes: By the end of the lesson, you must have: 1. Described nutritional needs of infants. 2. Assess infant’s nutritional needs based on growth charts. 3. Described methods to promote optimal nutritional intake. 4. Described assessment and intervention strategies for common infant health concerns. 5. Applied knowledge of the nutrient needs to the meal Warm-up Activity: Let’s see how broad is your knowledge prior to the start of your lesson. For three (3) minutes, try to answer the questions. After that, share your answer to the class. 1. What is the basic food of an infant? 2. Does exclusive breastfeeding include giving a small amount of water? environment. Learning Inputs: Normal gestation is 40 weeks. The average birth weight of an infant ranges between 5.5 and 10 lb; the average is approximately 7–7.5 lb. Healthy, full-term infants lose some weight in the first days after birth but tend to regain it within the first week. Infants often double their birth weight by 4–6 months and triple it within 1 year. For assessment of an infant, monitoring growth is the best way to evaluate intake. Head circumference increases about 40% during the first year, and brain weight should almost double Infants are composed of approximately 75–80% water, whereas adults are composed of 60–65% water. Infants may become dehydrated easily, especially in hot weather or after bouts of diarrhea.  Breast milk excels as the source of nutrients for infants  ADA recommends exclusive breastfeeding from four to six months (Grodner, 2000)  Breastfeeding with complementary foods for at least 12 months  Breastfeeding 8-12 feedings/day or per demand, 10-15 mins/breast Infants older than 6 months of age are beginning the developmental stages that will lead to walking and talking. Many of the same principles NCM 105: NUTRITION AND DIET THERAPY 11  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences associated with infant feeding during the first 6 months will continue with the greater use of solids. The growth pattern of breastfed and formula-fed infants differs in the first 12 months of life. Timing of the introduction of complementary foods (solids) is an important consideration. A. Factors Affecting Nutritional Status 1. Breastfeeding for 4-6 months (exclusive) “Breast milk provides immunologic and protective factors  Antibodies (-Ig A)  Oligosaccharides (prevents pathogens from binding to intestinal cells  Bifidus factors (favors growth of friendly bacterium) Lactobacillus bifidus (lessens harmful bacteria)  Lactoferrin (Iron Binding CHON in breastmilk)-(helps absorb iron into infant’s intestinal walls/cells  Lactadherin(protein in breastmil, inhibits replication of virus that causes diarrhea)  Lipase (an enzyme that protects against infection) 2. Introduction of solid foods (ages between 4-6 months) Two Basic Concerns a. How to introduce solid foods? Ensure that the baby should be developmentally ready for solid foods. Cues: 1. Infant is able to sit with some support 2. Can move the jaw and lips, and the tongue independently 3. Able to roll tongue to the back of the mouth to facilitate bolus in entering the esophagus 4. Shows interest in what the rest of the family is eating Parents/caregivers should be familiar with satiety cues – so as not to overfeed the baby Satiety cues: 1. turns to the side 2. refuses to open mouth NCM 105: NUTRITION AND DIET THERAPY 12  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 3. Grimaces when spoon comes close to the mouth b. What are the appropriate solid foods for the first year of life? Primary Food – breast milk Complementary foods – solid foods Should be gradually introduced one at a time with 4- 5 days interval between new food Solid foods during the 1st Year of Life Age Food Avoided Foods 4-5 mos. Iron-fortified Honey cereals Hotdogs, grapes, 5-6 mos. Strained fruits hard candles, raw and vegetable carrot, popcorn, 6-8 mos. Mashed/ nuts, Peanut butter, chopped fruits skim milk, cow’s and vegetables milk, egg white 9-12 mos. Crackers, toast, cottage cheese, plain meals, egg yolk, finger foods B. Energy & Nutrient Needs During Infancy 1.ENERGY  WHO: Infants receive:  108 kcal/kg/day – 1st 6 months  98 kcal/kg/day – from 6 months to 1 year old  Should not be restricted on fat intake  Human milk: high in cholesterol & fat specifically omega-3 fatty acid 2.CHONs  CHON requirement highest: 1st 4 months of life where growth is most rapid  Infants should receive:  2.2 g/kg/day – birth to 6 months  1.6 g/kg/day – 2nd half to 1st year  Excess protein should be avoided NCM 105: NUTRITION AND DIET THERAPY 13  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 3.VITAMINS & MINERALS  Breast milk & Commercial Formula should provide all the vitamins & minerals  Iron  Folate  Calcium 4.WATER  Breast milk provides enough water C. Nutritional Problems 1.Baby Bottle Tooth Decay (BBTD) – Nursing bottle caries/ Nursing bottle mouth syndrome  Tooth decay in infants affecting primarily maxillary incisors  Common when infants sleep with a bottle of milk, juice or sweetened liquid  Liquid pools in infants mouth becoming a source of fermentable carbohydrate for the bacteria to colonize oral cavity  Acid produced by bacteria destroys tooth enamel 2.Inborn Errors of Metabolism a. Phenylketonuria (PKU)  Phenylalanine cannot be converted to tyrosine  Toxicity may result to damage of CNS: mental retardation  Dietary Therapy  Low Phenylalanine diet  Lofenalac formula  Low CHON breads and pasta b. Galactosemia  Inability to metablize galactose due to absence of the enzyme galactose 1-phosphate uridylytransferase *Lactose = Galactose + Glucose  Infants unable to tolerate lactose in milk products  s/s : diarrhea, growth retardation, mental retardation  tx: exclude all milk products including human milk NCM 105: NUTRITION AND DIET THERAPY 14  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences  Soy formula and casein hydrolysate formula may be given Activity 1. Analyze the sample nursing care process related to nutrition of an infant. Inadequate Iron Intake Assessment Data: Food records; lab reports for H & H, serum ferritin. Nutrition Diagnoses (PES): Inadequate mineral intake related to intake of insufficient amounts of iron-fortified formula as evidenced by mother’s report of diluting formula with cow’s milk for infant at 3 months of age to save money. Intervention: Education about appropriate preparation and use of formula for infants. Referral to WIC program if eligible. Monitoring and Evaluation: Lab reports for H & H, serum ferritin; dietary history indicating proper use of iron-fortified formula. Wrap-up Activity: It is particularly important that babies have adequate diets so that their physical and mental development are not impaired. Breastfeeding is nature’s way of feeding an infant, although formula feeding is quite acceptable. Cow’s milk is usually used in formulas because it is most available and is easily modified to resemble human milk. The young child’s diet is supplemented on the advice of the pediatrician. Added foods should be based on MyPyramid. Inborn errors of metabolism cause various problems, ranging from mental retardation to death, if not properly treated. In these conditions, diet therapy is the primary tool in maintaining the patient’s health. After you have learned the concepts of nutrition during infancy, why should the mother give her baby special attention during feedings? Post-Assessment: A quiz will be uploaded in the mVLE after the discussion. References: Caudal, M.C. (2008). Basic Nutrition and Diet Therapy: Textbook for Nursing Students Revised ed. C&E Publishing, Inc. NCM 105: NUTRITION AND DIET THERAPY 15  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Escott-Stump, Sylvia. (2008) Nutrition and diagnosis-related care /Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins, Williams, S. R. (2001). Basic nutrition and diet therapy. St. Louis: Mosby. Lesson 3 NUTRITION IN CHILHOOD Although specific nutritional requirements change as children grow, nutrition always affects physical, mental, and emotional growth and development. Studies indicate that the mental ability and size of an individual are directly influenced by nutrition during the early years. Children who have an inadequate supply of nutrients—especially of protein—and calories during their early years may be shorter and less intellectually able than children who receive an adequate diet. Learning Outcomes: By the end of the lesson, you must have: 1. Described nutritional needs in childhood. 2. Assess the different stage of childhood’s nutritional needs based on growth charts. 3. Described methods to promote optimal nutritional intake. 4. Described assessment and intervention strategies for common to childhood health concerns. 5. Applied knowledge of the nutrient needs to the meal Warm-up Activity: Before you proceed to learning inputs, answer this question, what effects might be expected later in life from foods inadequate in quantity and quality during the growing period? environment. Learning Inputs: CHILDHOOD (1-12 years old) While children are not “little adults” and should be treated individually, conversation with an adult is usually required to discuss actual food intake by a child. The ability to recall by children is often limited because of vocabulary and attention span. Children benefit from training, such as with pictures, food models and cups. Growth during this stage involves changes in appetite, physical activity, and frequency of NCM 105: NUTRITION AND DIET THERAPY 16  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences illnesses. The CDC growth charts provide a guideline for monitoring successful growth related to weight, height, and age. A. Caloric requirements:  1 year old – 800 kcal/day  Active 6 y/o – 1,600 kcal/day  Active 10 y/o – 2,000 kcal/day Feeding relationship  Interaction or patterns of behaviors that surround food preparation and consumption within a family. B. Nutritional Requirements Carbohydrates  Most important energy source for children  Should eat it in its complex form such as fruit, vegetables and wholegrain cereals Protein  Need for protein increase steadily throughout as both hard and soft tissue continue to form.  Protein forms the matrix of all tissue in the body. B group vitamins  Allows energy to be released Calcium  Needed for the ossification process of bone and teeth  It is required in large amount during childhood. Iron  Required for the increase in blood volume as the body grows larger. NCM 105: NUTRITION AND DIET THERAPY 17  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Table 3. Recommendation for Children C. Considerations 1. Children depend on adults for provision of food. 2. Adults control the quantity and quality of food, children control amount consumed. 3. Regularity of mealtime at home during breakfast and dinner supports success at school. 4. Snacks should boost daily nutrient intake. 5. Sugars displace nutritious foods. 6. Television commercials influence children’s food choices D. Milestones Stage I: 1-3 y/o – toddlerhood  1,300 kcal/day  CHON - 16 g  2-3 (8 ounce) or 16-24 ounces / day milk intake Features/Considerations: o Early relationship between parents or caregivers and child is formed NCM 105: NUTRITION AND DIET THERAPY 18  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences o Development autonomy is evident o *self-reliance by allowing children to feed themselves appropriate to motor activities o Consistency of mealtime should be observed Stage II: 4-6 y/o  1,800 kcal/day  CHON – 24 g Features/Considerations: o Children have independent eating styles o They clearly understand the time frame of meals & can save their appetite for meals o They accept foods more easily if presented separately o Food jag – children want to eat only a narrow range of food Stage III: 7-12 y/o  2,000-2,200 kcal/day  CHON – 28-46 g Features/Considerations: o Sexual maturity leads to increase lean body mass o Actual growth may slow down – the body is preparing and seemingly storing up for the growth spurt during puberty E. NUTRITIONAL PROBLEMS AND CONCERNS 1. Iron deficiency  Iron is crucial to synthesize neurotransmitters, hence affects the ability of children to pay attention  Iron supplementation is important for learning and memory 2. Lead poisoning  Lead toxicity leads to diarrhea, irritability and fatigue  May lead also to impairment of cognitive and behavioral abilities  Two common sources: eating dirt & chips of paints NCM 105: NUTRITION AND DIET THERAPY 19  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 3. Food allergy  Adverse reaction to food that involves an immune response  Causes: peanut allergy (food preparation is usually attributed when roasting peanuts at a high temperature) it is more allergenic  Milk, egg, soy, peanut, fish, shellfish  Epinephrine – management of anaphylactic reactions 4. Food Intolerance  Unusual response to food that does not involve immune response  s/s stomach ache, headache, rapid pulse rate, nausea, wheezing, bronchial irritation Causes: Monosodium glutamate Prunes (natural laxative) Sulfur (digestive diseases) Lactose intolerance 5. Obesity  BMI at 95th percentile or 30 for adults  For 2 yrs old – weight for height values above 95 th percentile  Parental obesity predicts an early increase in BMI  Children with neither parents who are obese have a less than 10% chance of becoming obese Cause: added sugars (e.g. 12 ounce soft drinks=10 tsp sugar (150 kcal) 6. Dental caries  Sticky, sugary foods on teeth provides ideal environment for bacteria  Tooth brushing/flossing after eating should be encouraged  Brush/rinse teeth after snacks  Eat crisp/fibrous foods Activity 1. Analyze the sample nursing care process related to nutrition of a child. NCM 105: NUTRITION AND DIET THERAPY 20  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Lead Poisoning in Childhood Assessment Data: Dietary recall; labs such as H & H, serum feritin, and serum lead levels; growth charts. Nutrition Diagnosis (PES): Excessive bioactive substance intake related to lead consumption from lead-based paint exposure in environment as evidenced by high serum lead levels, documented ID anemia, and deposition seen on x-rays. Intervention: Education and counseling tips on avoiding accidental lead intake; increasing sources of iron and calcium in the diet; tips on reducing environmental lead sources; running water awhile before drinking. Monitoring and Evaluation: Reduced intake of sources of lead; improved lab values, improved weight gain on growth grid; successful growth and development. Limited Fruit-Vegetable Consumption Assessment Data: Dietary recall; growth charts; physical signs of malnutrition. Nutrition Diagnosis (PES): Inadequate vitamin intake (vitamin C) related to minimal consumption of fruits and vegetables as evidenced by diet history, no use of children’s vitamins or fortified foods, and signs of bleeding gums, petechiae, irritability, and easy bruising. Intervention: Education and counseling tips on improving intake of fruits and vegetables; recipes and tips for increasing citrus fruits and good sources of vitamin C in foods well accepted by children. Referral to WIC program if eligible. Monitoring and Evaluation: Improved signs of nutrition and resolution of bleeding gums, etc; diet history and mother’s description of improved vitamin C intake and financial assistance from WIC. Wrap-up Activity: NCM 105: NUTRITION AND DIET THERAPY 21  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences The terminology used with children needs to be concrete and nonscientific. Children cannot understand abstract concepts, such as the role of nutrients in foods, even though a young child can pronounce the words. Therefore, it is more appropriate to focus on promoting positive attitudes toward eating nutritious foods. Children can appreciate the concept that eating is fun, and this concept should be applied to nutritious foods. One method that strongly appeals to children (and even to the parents who may be present) is the use of puppet shows. What are some strategies that you can teach to the parent to make his/her child’s eating fun and encourage nutritious food? Post-Assessment: A quiz will be uploaded in the mVLE after the discussion. References: Caudal, M.C. (2008). Basic Nutrition and Diet Therapy: Textbook for Nursing Students Revised ed. C&E Publishing, Inc. Escott-Stump, Sylvia. (2008) Nutrition and diagnosis-related care /Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins, Williams, S. R. (2001). Basic nutrition and diet therapy. St. Louis: Mosby. Lesson 4 NUTRITION IN ADOLESCENCE The final growth spurt of childhood occurs with the onset of puberty. This rapid growth is evident in increasing body size and the development of sex characteristics in response to hormonal maturation. Because the velocity of growth and onset of puberty can vary greatly among individual boys and girls, biologic age is a better indicator of nutritional needs than chronologic age throughout adolescence. There are distinct patterns of body composition changes. Girls store more subcutaneous fat in the NCM 105: NUTRITION AND DIET THERAPY 22  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences abdominal area. The pelvis widens in preparation for future childbearing, and the size of the hips also increases, which causes much anxiety for many figure conscious young girls. In boys, physical growth is seen more in increased muscle mass and long-bone growth. At first a boy’s growth spurt is slower than that of a girl, but he soon surpasses her in both weight and height. Learning Outcomes: By the end of the lesson, you must have: 1. Described nutritional needs in adolescence. 2. Assess the different stage of adolescence’s nutritional needs based on growth charts. 3. Described methods to promote optimal nutritional intake. 4. Described assessment and intervention strategies for common to adolescence’s health concerns. 5. Applied knowledge of the nutrient needs to the meal environment. Warm-up Activity: Before you proceed to learning inputs, answer this question, is there any difference to the nutritional needs of a male and female adolescent? If there is, kindly enumerate and explain. Learning Inputs: Adolescents need to consume food and beverages that provide adequate energy and nutrients to reduce risk for poor outcomes including growth retardation, ID anemia, poor academic performance, development of psychosocial difficulties, and an increased likelihood of developing diseases such as heart disease and osteoporosis (American Dietetic Association, 2010). Breakfast consumption is important to enhance cognitive function related to memory, test grades, and school attendance. Dietary intake and body size influence age at menarche and growth patterns in teen girls. Puberty comes early for some girls because of a gene (CYP1B1) that speeds up the body’s breakdown of androgens as well as percentage of energy intake from dietary protein. Teens should have NCM 105: NUTRITION AND DIET THERAPY 23  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences access to an adequate supply of healthful and safe foods that promote optimal physical, cognitive, and social growth and development; nutrition assistance programs play a vital role (American Dietetic Association, 2010). ADOLESCENCE (13-19 years old)  Females: 2,200 kcal/day, 45 g CHON/day  Males: 2,500-2,900 kcal, 45-49 g CHON *KOSHER meal – lactose reduced meal A. Features/Considerations:  Growth spurts  Emotional & social developmental struggles  Eating habits – some teens adopt vegetarian diets Fast food consumption B. Nutritional Needs  Protein  Needed for rapid growth of soft tissue as well as bone lengthening  Needed for the formation of hormones  Carbohydrates  During the growth spurt energy needs are high but after the main years of growth, energy needs are related more to physical activity levels.  Vitamin C  Needed to release energy  Works together with protein to form connective tissue, also needed for the absorption of iron.  B group vitamins  Required for energy levels: quantities increase according to energy levels.  Calcium  Needed for the lengthening and ossification of bones  They need to reach their peak bone mass NCM 105: NUTRITION AND DIET THERAPY 24  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences  Calcium in the bloodstream is important for muscle contraction and conduction of nerve impulses.  Iron  Needed for the increase in blood volume, energy and for females to help replace the blood lost during menstruation. Table 4. Recommendations for Adolescents C. COMMON NUTRITIONAL PROBLEMS 1. Food asphyxiation 2. Lead poisoning 3. Obesity 4. Iron Deficiency Anemia 5. Food Allergies & food intolerances 6. Eating disorders: a. Anorexia nervosa  Mental disorder characterized by self-imposed starvation  May include binge eating episodes associated with bulimic behaviors  Individuals have:  Distorted body image – they do not see themselves as underweight. Thus they continue to restrict their food intake, often in a ritualistic manner NCM 105: NUTRITION AND DIET THERAPY 25  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences  Obsession with body shape and weight  Intense phobia of obesity  Compulsive behaviors (excessive exercises, ritualistic personal hygiene behaviors, intensive study work behaviors) Physiologic changes (s/s)  Amenorrhea  Electrolyte imbalances  Cardiovascular problems (hypotension, arrhythmias)  Hormonal imbalances  Hypothermia  Constipation  Vitamin, mineral & protein deficiencies  s/s of starvation – fatigue, loss of endurance b. Bulima Nervosa (binge-purge syndrome)  bulimic behaviors which include repetitive food binges accompanied by purging/compensatory behaviors  Bingeing – feeling out of control when eating resulting consumption of excessive amount of food  Purging – use of laxatives, diuretics and self-induced vomiting o May lead to dehydration, electrolyte imbalances, metabolic alkalosis, sore throat, hormonal imbalances, blood-shot eyes, broken blood vessels of the face  Inappropriate compensatory behaviors – fasting, diet pills, excessive exercises c. Binge-eating disorder (compulsive over-eating)  Mental disorder characterized by binge eating not accompanied by purging or compensatory behavior  Triggered by stressful events, anxiety depression  May occur in secret or private settings  After binge eating, there is a feeling of low-esttem, shame, remorse, and depression Nutritional Therapy NCM 105: NUTRITION AND DIET THERAPY 26  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences o Use of specific diet therapy & counseling Activity 1. Analyze the sample nursing care process related to nutrition of an adolescent. MEGAN: IDENTIFYING ANOREXIA NERVOSA Megan is an active 12-year-old Megan to finish her meal, her Caucasian girl. She loves to play mother would step in and say, “If hard and is an avid reader. She she isn’t hungry, don’t force her.” has been growing like a weed and Megan oftentimes complains of seems to have just the right bone pain. Her parents call it amount of love and caring from growing pains, and there is a her family. She is proud to be history of severe arthritis in her “almost as tall as her family. Megan’s complexion is grandmother.” She is 5 feet tall very pale. After school Megan and weighs 70 pounds. Megan comes home and eats a piece of can wear some of her summer fruit and then says she is not shorts from 3 years ago. They hungry at mealtime. Once when may be short, but they fit her at her grandmother’s house, waist and hips. When Megan sat Megan said she was hungry but down to a meal with her family, was not going to allow herself to she would eat slowly and eat. Her grandmother informed oftentimes not finish her meals, her parents of this right away. saying she was too full. Her Since that statement, both grandmother noticed, at parents and the grandmother are mealtime, that her dad would watching Megan’s eating habits. make sure her little sister ate well, but when telling ASSESSMENT 5. What would lead you to believe 1. What objective information do Megan may be having you have about Megan? appearance issues? 2. What subjective information do DIAGNOSIS you have about Megan? 6. Complete the following 3. Which psychological issues are statement: Megan’s imbalanced having an effect on Megan’s nutrition is secondary to understanding of proper nutrition? ___________. 4. What are the psychological 7. What signs of anorexia nervosa needs of preteens? does Megan exhibit? PLAN/GOAL NCM 105: NUTRITION AND DIET THERAPY 27  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 8. What is the major nutritional Does anorexia nervosa have an goal for Megan? age limit? 9. What is the priority for Megan’s EVALUATION/OUTCOME CRITERIA physical 14. What criteria could be used to development? demonstrate that her anorexia IMPLEMENTATION nervosa was under control? 10. What should Megan and her 15. Can anorexia nervosa be mother be taught about good cured? nutrition? THINKING FURTHER 11. What needs to be taught 16. How can parents, teachers, about anorexia nervosa? Who else and coaches help the young needs this information? preteens who have eating 12. Would a counselor be of disorders? assistance to Megan and her 17. Will Megan’s younger sister mother? be at risk for anorexia nervosa? 13. What can be done to prevent anorexia nervosa in her sister? Wrap-up Activity: During adolescence, growth is rapid, and nutritional and calorie requirements increase substantially. Anorexia nervosa, bulimia, and obesity are problems of weight control that can occur during adolescence. Fast foods are acceptable when used with discretion in a balanced diet. Alcohol can be a serious problem for adolescents, and it is essential that adolescents understand its potential dangers. Post-Assessment: A quiz will be uploaded in the mVLE after the discussion. References: Caudal, M.C. (2008). Basic Nutrition and Diet Therapy: Textbook for Nursing Students Revised ed. C&E Publishing, Inc. Escott-Stump, Sylvia. (2008) Nutrition and diagnosis-related care /Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins, Williams, S. R. (2001). Basic nutrition and diet therapy. St. Louis: Mosby. NCM 105: NUTRITION AND DIET THERAPY 28  Lesson 5 NUTRITION IN ADULT YEARS AND AGING The rapid growth and development of adolescence leads to physical maturity as adults. Physical growth in size levels off, but the constant cell growth and regeneration that are necessary to maintain a healthy body continue. Other aspects of growth and development— mental, social, psychologic, and spiritual—continue for a lifetime. Food and nutrition continue to provide essential support during the adult aging process. Life expectancy is increasing; thus, health promotion and disease prevention are even more important to ensure quality of life throughout these extended years. This chapter explores the ways in which positive nutrition can help adults to lead healthier, disease-free lives. Learning Outcomes: By the end of the lesson, you must have: 1. Described nutritional needs in adult years. 2. Assess the different stage of adult’s nutritional needs based on growth charts. 3. Described methods to promote optimal nutritional intake. 4. Described assessment and intervention strategies for common to adult’s health concerns. 5. Applied knowledge of the nutrient needs to the meal Warm-up Activity: Before you proceed to learning inputs, answer this question, why is it necessary to understand the physiologic changes that occur with aging? environment Learning Inputs: The extension of life expectancy has had and will continue to have a profound effect on society and the health care system. This is particularly true for adults who did not follow healthy guidelines during their youth or young adulthood and have to contend with chronic disease related to obesity. It is expected that the younger generations today will actually see a shortened life span due to cardiovascular disease, diabetes, renal disease, and cancer, all related to obesity and the metabolic syndrome. On the other hand, there are many health conscious and physically active individuals, who are in many ways healthier than their earlier counterparts.  Many of today’s older adults are very different from those of past generations. It has been said that 50 is the new 30, and for many 50-year- olds, being labeled “middle-aged” does not have the same connotation as it once did. Increasingly, older adults are working far past the traditional retirement age of 65 years. Older adults in their 60s and 70s may even be more physically fit than in their younger years because they have increased time for physical activity. Other, relatively young adults may already be frail and in poor health because of chronic health problems or a lifetime of poor nutritional intake and substance abuse. After the age of 80 there are physical declines for all. However, this elder population may still have much to contribute to society, such as being surrogate parents for grandchildren or even great-grandchildren. Even into the 90s more and more elder adults are maintaining their independence and are providing a unique perspective on life for the younger generations. Increasing numbers of adults are living past 100 years of age. ADULTHOOD Nutrient and dietary patterns directly influence the risks of developing chronic disorders of osteoporosis, coronary artery disease diabetes, hypertension, and obesity. A. Effects of Aging (Grodner) Effects on the Causes Organ involved nutritional Status o Decreased o Decreased o Tongue and nose ability to taste taste buds salt and sweets o Decreased o Decreased palatability of taste and foods, taste, olfactory and smell. nerve endings Food intake o Reduced o Decreased o Salivary glands sense of saliva thirst/dry production mouth, difficulty chewing o Minor effects o Muscle o Esophagus  on swallowing contractions may malfunction o Decreased o Decreased o Stomach absorption of HCL secretion vitamins, and intrinsic minerals, factor CHONs o Decreased o Decreased absorption of pepsin Vit B12 and Folate Table 5. Effects of Aging to Nutrition B. STAGES OF ADULTHOOD 1. Early years (20s and 30s)  Lifestyle: focused on personal, family and career goals  Faced with reproductive decisions  Focus of Nutrition  Refinement and establishment of eating styles on health promotion and preventing the development of diet-related diseases  Nutrition and health requirement of pregnancy Nutritional Requirements RDA: Female: 2,200 kcal 46-50 g CHON Male: 2,900 kcal 58-63 g CHON 2. Middle years (40s and 50s)  Continuation of family and career demands  Faced with more responsibilities like caring for aging parents  “Empty nest” necessitates meals for two  Regular exercise continued prevention or delay of diet-related diseases such as type 2 DM and CAD  Physiologic changes:  Loss of lean body mass  Lean body mass replaced by body fat Nutritional Requirements  RDA: Females: 1920 kcal/day Males: 2300 kcal/day Lower fat CHON with high fiber foods 3. Older years (60s, 70s, and 80s)  Adults are in transition, adopting to retirement, setting into new patters of activities  Disorientation or senility may result to marginal nutrient deficiencies  Intentional restrictions of fluid intake due to incontinence  Decreased production of intrinsic factor for Vit B12 absorption  Marginal deficiency of zinc can alter sensitivity of taste receptors( this deficiency heightens the ability to taste bitter and sour flavors and reduces sweet and salty sensations thus excessive use of sugar and salt)  Loss of teeth due to periodontal diseases which limit chewing of meat 4. Oldest years (80s and 90s)  Aging may reduce ability of the body to absorb and synthesize nutrients  Most at risk of dehydration due to decreased ability of kidneys to concentrate urine  Increase fear of incontinence leads to decreased fluid intake Table 6. Nutrient Recommendations for Adults BARRIERS 1. Food asphyxiation 2. Stress 3. Breast Cancer - Avoid large amounts of soy if breast cancer is a known risk. Black cohosh has some merit but may also have undesirable side effects 4. Menopause - Declining levels of estrogens and other hormones, cessation of menstrual periods, and a decreased need for iron. Hormone replacement therapy is no longer the mainstay for preventing osteoporosis and fractures because of the risk for cancer. Exercise, calcium, vitamin D and physical examinations are needed. A diet that is moderate in carbohydrate slows insulin shifts; lean proteins and moderate fat help to prevent weight gain. Food sources of selenium, vitamins C and E contribute antioxidant benefits. Whole grains, flax seed, and other omega-3 fatty acids may reduce the inflammation that aggravates hot flashes. Phytoestrogens from isoflavones, lignans, and coumestans (soy foods, flaxseed, and red clover) are useful for some women. 5. Alcohol - This is a major problem among the elderly, especially for those living alone. Other drugs, either prescribed or illegally obtained, also interfere with the body’s use of nutrients. Alcohol-drug interactions influence the entire life span, as does the abuse of prescription drugs. 6. Prostate Cancer - Proscar (finasteride) and other medications are used with some relief. Monitor blood pressure; no nutritional side effects are noted. Saw palmetto may be useful (see following herb section). - Antioxidant foods may help protect against prostate cancer. Brazil nuts, seafood, and whole grains are natural sources of selenium. Lycopene from dietary sources (tomato sauce, pink grapefruit) are  preferable over supplements. Broccoli and cauliflower also be protective. Activity 1. Describe an appropriate response to your 65-year-old aunt, who has just become captivated by a salesperson in a local health food store and has announced that she is buying a 6-month supply of vinegar-honey tablets that are guaranteed to prevent arthritis. Wrap-up Activity: Meeting the nutrition needs of adults—especially older adults—may present a challenge for several reasons. Current and past social, economic, and psychologic factors influence needs, and the biologic process of aging differs widely among individuals. As the average life expectancy continues to increase, research and recommendations regarding the needs of an aging population are updated. Many illnesses in older adults are the result of malnutrition rather than the effects of aging. Health promotion and disease prevention during early adulthood are key elements to sustain functionality throughout the later years. When working with older people, health care professionals must analyze food habits carefully and approach clients with encouragement for positive changes to be made. Individual supportive guidance and patience are necessary when administering nutrition resources and support. Post-Assessment: A quiz will be uploaded in the mVLE after the discussion. References: Caudal, M.C. (2008). Basic Nutrition and Diet Therapy: Textbook for Nursing Students Revised ed. C&E Publishing, Inc. Escott-Stump, Sylvia. (2008) Nutrition and diagnosis-related care /Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins, Williams, S. R. (2001). Basic nutrition and diet therapy. St. Louis: Mosby.  Lesson 6 NUTRITION IN AGING Aging involves a progression of physiological changes with cell loss and organ decline. Decreased glomerular filtration rate (GFR) and creatine-height index (CHI), constipation, decreased glucose tolerance, and lowered cell-mediated immunity can occur. Energy needs for basal metabolism decrease as much as 10% for ages 50–70 years and by 20– 25% thereafter. Life span is the length of time an organism could live; for humans, this is between 120 and 140 years. But life expectancy (average life span) is seldom beyond 114 years. Many gerontologists prefer to have patients start out a little overweight to support immunity. Nutrition density is an integral part of successful aging; culturally appropriate food and nutrition services should be customized to the individual’s needs. It is estimated that most of the older population have one or more chronic conditions that would benefit from nutrition interventions. Challenges of nutritional assessment in older adults include limited recall, hearing and vision losses, changes in attention span, and variations in dietary intake from day to day. The inability to perform activities of daily living can be a major concern. Older adults may need assistance with shopping, meal preparation, and in ensuring adequate intake. Food insecurity exists among senior citizens and should be addressed. Learning Outcomes: By the end of the lesson, you must have: 1. Described nutritional needs in aging years. 2. Assess the different stage of agings’s nutritional needs based on growth charts. 3. Described methods to promote optimal nutritional intake. 4. Described assessment and intervention strategies for common to aging’s health concerns.  5. Applied knowledge of the nutrient needs to the meal Warm-up Activity: Before you proceed to learning inputs, answer this question, do you think that the advance aged groups require a special care in their nutrition? If yes, in what particular aspect? environmen Learning Inputs: Although the biologic changes of senescence are generally similar, each person is unique, and people show a wide variety of individual responses. Individuals age at different rates and in different ways, depending on their genetic heritage and the health and nutrition resources of their prior years. For example, some individuals are in the best shape of their lives after retirement when given the extra time to eat and exercise freely and without stressful time constraints. Thus, specific needs vary with functional ability. A. Nutrition Assessment Tools for the Aging Table 7. DETERMINE Checklist DISEASE Any disease, illness, or chronic condition that causes changes in eating habits or makes eating difficult increases nutritional risk. Four of every five adults have chronic diseases that are affected by diet. Confusion or memory loss that keeps getting worse is estimated to affect one or more in five older adults. This can make it hard to remember what, when, or if food has been eaten. Feeling sad or depressed, which happens to about one in eight older adults, can cause big changes in appetite, digestion, energy level, weight, and well-being. EATING POORLY Eating too little or too much leads to poor health. Eating the same foods day after day or not eating fruit, vegetables, and milk products daily will also cause poor nutritional health. One in five adults skips meals daily. Most adults do not eat the minimum amount of fruit and vegetables needed. One in four adults drinks too much alcohol. Many health problems become worse if more than one or two alcoholic beverages are consumed daily. TOOTH LOSS OR MOUTH PAIN A healthy mouth, teeth, and gums are needed to eat. Missing, loose, or rotten teeth or dentures that do not fit well or cause mouth sores make it hard to eat. ECONOMIC HARDSHIP Many older Americans have fixed incomes that may interfere with adequate funds to purchase foods. REDUCED SOCIAL CONTACT One third of all older people live alone. Being with people daily has a positive effect on morale, well-being, and eating habits. MULTIPLE MEDICINES Many older Americans must take medicines for health problems. Almost half of all older Americans take multiple medicines daily. Growing old may change the way we respond to drugs. The more medicines used, the greater the chance for side effects, such as increased or decreased appetite, change in taste, constipation, weakness, drowsiness, diarrhea, and nausea. When taken in large doses, vitamins and minerals act like drugs and can cause harm. Doctors need to be alerted to all medications taken. INVOLUNTARY WEIGHT LOSS OR GAIN Losing or gaining a lot of weight when not trying to do so is an important sign that must not be ignored. Being overweight or underweight also increases the chance of poor health.  NEEDS ASSISTANCE IN SELF-CARE Although most older people are able to eat, one in five has trouble walking, shopping, and buying and cooking food. ELDER YEARS ABOVE AGE 80 Most older persons lead full and productive lives. But as age increases, risk of frailty and health problems increase. Older persons should check their nutritional health regularly. Table 7. Non-physiological Causes of Undernutrition B. Nutritional Requirements in Aging Table 8. Nutritional Requirements in Aging C. Nutritional Interventions  Provide proper nutrition for weight control, healthy appetite, prevention of acute illness, and complications of chronic diseases such as osteoporosis, fractures, anemia, obesity, diabetes, heart disease, and cancer.  Avoid rapid unintentional weight loss, which often indicates underlying disease and accelerated muscle loss. Determine baseline functional level and evaluate changes over time.  Monitor signs of malnutrition. Prevalence increases with age, is more common in institutionalized individuals, and is associated with susceptibility to infection, longer hospital stay, and increased mortality. Malnutrition may be caused by poverty, ignorance, chronic disease, poor dietary intake, chewing or swallowing problems, polypharmacy, mental or physical disability, even depression. MIA syndrome reflects the triad of malnutrition, inflammation, and atherosclerosis that often includes oxidative stress and elevated cytokines.  Correct existing nutritional deficiencies. Avoid restrictive diets as much as possible.  Recognize cachexia syndromes that are not reversible by hypercaloric feeding. Sometimes failure of nonpharmacologic therapies warrant consideration of orexigenic drug therapy. Malnourished older adults benefit from receiving oral supplemental beverages.  Vitamin B12 deficiency in older people is most often from malabsorption of food-bound vitamin B12. High serum folate levels along with vitamin B12 deficiency exacerbate anemia and can worsen cognitive symptoms, therefore careful monitoring is important.  Provide foods of proper consistency by dental status. Dentures alter the taste of foods by increasing bitter and sour taste sensations. Chop foods as needed; puree only if necessary.  Provide a diet of correct texture; exclude hard, sticky foods that are difficult to chew and swallow.  Older individuals have fewer taste buds. More sweet flavors and stronger seasonings may be required to satisfy the appetite.  Evaluate for laxative and enema use or abuse; recommend suitable alternatives and interventions, such as oat fiber, prunes or other dried fruits, extra liquid.  Evaluate for alcohol abuse; make appropriate referrals as needed.  “If the gut works, use it.” Maintain oral diet as much as possible. For individuals who are unable to regain unintentional weight  losses, artificial nutrition may be needed. Review advance directives and proceed accordingly.  Investigate hydration status and any major weight shifts. Diminishing thirst mechanisms and incontinence contribute to dehydration. Generally, older adults should ingest 25–30 mL/kg of fluids per day. Alterations would be needed for heart, liver, or renal failure.  Indices of overweight and obesity such as BMI do not correlate as strongly with adverse health outcomes in older as compared to younger individuals.  Assess the behavioral and environmental situations (i.e., Who shops? Who cooks? How are finances handled? How often are meals eaten away from home? Is this person dependent or independent?). Evaluate family and social support. If there is a need for assistance, make appropriate referrals.  Correct frailty where possible by addressing depression, use of multiple medications, underlying medical illnesses. Low levels of serum cholesterol (_189 mg/dL) may indicate signs of occult disease or rapidly declining health.  Encourage physical activity, especially resistance training. This can help to maintain metabolically active tissue, stimulate appetite, improve sleep, correct mild constipation, improve cognitive function, enhance nitrogen balance, and promote positive outcomes in memory, self-esteem, and independence. D. Nutritional Health Problems in Aging Many of the health problems of the elderly are nutrition related. Some examples are discussed below. 1. Nutrient deficiencies—Recent studies have shown that the elderly are often deficient in protein, iron, calcium, and vitamins A and C. This increases the incidence of iron-deficiency anemia and osteoporosis, decreases resistance to infections, and lowers overall health status. 2. Osteoporosis—This disorder remains a major health problem among the elderly, especially women past the age of 60. Although the symptoms appear after menopause, researchers agree that the disorder begins as early as age 30. The 1989 RDAs reflect the young woman’s increased needs. At present, no kno0wn preventive measure exits, but symptoms can be minimized with an adequate diet and regular exercise. Some believe that limited alcohol and caffeine consumption and a moderate fiber intake can also help.  Extra calcium may be helpful, and some studies indicate that fluoride may increase bone density and relieve some symptoms. 3. Diabetes—Noninsulin-dependent diabetes is a common problem among middle-age and elderly people. Approximately 75% of those with diabetes of this type are overweight or obese. In most patients, the disease can be controlled by diet alone, and the most effective treatment is to reduce to and maintain a normal body weight. 4. Diverticulosis—This widespread problem is characterized by a weakening of the intestinal walls, resulting in diverticulosis. Low- fiber diets, along with weakened muscle tissue, are believed to be a causative agent in this disease. 5. Hypertension— Two nutritional factors believed to play a role in hypertension are salt and body fat. Excessive weight or obesity appears to be a more important factor than a high intake of salt. Recent studies indicate that a calcium deficit may also contribute to the incidence of hypertension. 6. Atherosclerosis—This is a leading medical problem in the elderly and can result in heart attack or stroke. Coronary heart disease is the leading cause of death in the United States. Diet is one of the risk factors involved in the development of the plaque that narrows the lining of the arteries and blocks the blood flow. Activity 1. Search the Web for information on exercises that are appropriate for the elderly. What information can you find? Create a list of references of safe and effective exercises for the elderly. What benefits can these exercises bring to the elderly client? If an elderly client is active, what effect does that have on his or her nutritional needs? Wrap-up Activity: It is becoming apparent that many of the chronic diseases of the elderly could be delayed or avoided by maintaining good nutrition throughout life. Most nutrient requirements do not decrease with age, but calorie requirements do. When food habits of senior citizens must be changed, adjustments require great tact and patience on the part of the dietitian. Older people are easily attracted to food fads that promise good health and prolonged life. Post-Assessment: A quiz will be uploaded in the mVLE after the discussion. References: Caudal, M.C. (2008). Basic Nutrition and Diet Therapy: Textbook for Nursing Students Revised ed. C&E Publishing, Inc. Escott-Stump, Sylvia. (2008) Nutrition and diagnosis-related care /Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins, Williams, S. R. (2001). Basic nutrition and diet therapy. St. Louis: Mosby.