Diet During Pregnancy and Lactation PDF

**DIET DURING PREGNANCY AND LACTATION** Good nutrition during the 38 to 40 weeks of a normal pregnancy is essential for both mother and child. In addition to her normal nutritional requirements, the pregnant woman must provide nutrients and calories for the fetus, the amniotic fluid, the placenta,...

**DIET DURING PREGNANCY AND LACTATION** Good nutrition during the 38 to 40 weeks of a normal pregnancy is essential for both mother and child. In addition to her normal nutritional requirements, the pregnant woman must provide nutrients and calories for the fetus, the amniotic fluid, the placenta, and the increased blood volume and breast, uterine, and fat tissue. 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. **WEIGHT GAIN DURING PREGNANCY** Weight gain during pregnancy is natural and necessary for the infant to develop normally and the mother to retain her health. In addition to the developing infant, the mother's uterus, breasts, placenta, blood volume, body fluids, and fat must all increase to accommodate the infant's needs (Table 11-1). The average weight gain during pregnancy is 25 to 35 pounds. During the first trimester of pregnancy, there is an average weight gain of only 2 to 4 pounds. Most of the weight gain occurs during the second and third trimesters of pregnancy, when it averages about 1 pound a week. This is because there is a substantial increase in maternal tissue during the second trimester, and the fetus grows a great deal during the third trimester. Weight gain varies, of course. A pregnant adolescent who is still growing should gain more weight than a mature woman of the same size. Underweight women should gain 28 to 40 pounds. Women of average weight should avoid excessive weight gain and try to stay within the 25- to 35-pound average gain. If the woman is pregnant with twins, then the recommended weight gain is 35 to 45 pounds. Overweight women can afford to gain less than the average woman, but not less than 15 pounds. 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. **NUTRITIONAL NEEDS DURING PREPREGNANCY** Ideally when couples decide to have a child, they should make an appointment with their physician to discuss any health concerns or needed changes to the woman's diet. At that time the physician needs to emphasize the importance of the woman taking a folic acid supplement at least 1 month prior to conception. During the 1990s, researchers established a correlation between taking folic acid before pregnancy and during the first trimester and having babies with brain and spinal cord defects. The results of this research led the U.S. government to require the addition of folic acid to grain products. The U.S. Public Health Service and the March of Dimes recommend that all women of childbearing age take a multivitamin or 400 microgram of folic acid daily. Lifestyle and habits also need to be taken into consideration before becoming pregnant. Certain medications, smoking, illegal drugs, and alcohol can all be detrimental to the embryo. Good nutrition is essential before becoming pregnant and during pregnancy. Some specific nutrient requirements are increased dramatically during pregnancy, as can be seen in Table 11-2. The physician may suggest alternative figures based on the client's nutritional status, age, and activities. The protein requirement is increased by 20% for the pregnant woman over 25 and by 25% for the pregnant adolescent. Proteins are essential for tissue building, and protein-rich foods are excellent sources of many other essential nutrients, especially iron, copper, zinc, and the B vitamins. Current research indicates there is no need for increased vitamin A during pregnancy. Excess vitamin A (more than 3,000 RE) has been known to cause birth defects such as hydrocephaly (enlargement of the fluid-filled spaces of the brain), microcephaly (small head), mental retardation, ear and eye abnormalities, cleft lip and palate, and heart defects. The required amount of vitamin D is 10 microgram. The requirement for vitamin E is 15 mg-TE. The amount of vitamin K required is given as AI of 75 to 90 microgram depending upon age. The requirements for all the water-soluble vitamins are increased during pregnancy. Additional vitamin C is needed to develop collagen and to increase the absorption of iron. The B vitamins are needed in greater amounts because of their roles in metabolism and the development of red blood cells. The requirements for the minerals calcium, iron, zinc, iodine, and selenium are all increased during pregnancy. Calcium is, of course, essential for the development of the infant's bones and teeth as well as for blood clotting and muscle action. If the mother is not consuming adequate calcium in her diet, the baby will get its calcium from her bones. The need for iron increases because of the increased blood volume during pregnancy. In addition, the fetus increases its hemoglobin level to 20 to 22 grams per 100 ml of blood. This is nearly twice the normal human hemoglobin level of 13 to 14 mg per 100 ml of blood. The infant's hemoglobin level is reduced to normal shortly after birth as the extra hemoglobin breaks down. The resulting iron is stored in the liver and is available when needed during the infant's first few months of life, when the diet is essentially breast milk or formula. Therefore, an iron supplement is commonly prescribed during pregnancy. However, if the pregnant woman's hemoglobin remains at an acceptable level without a supplement, the physician will not prescribe one. **FULFILLMENT OF NUTRITIONAL NEEDS DURING PREGNANCY** Special care should be taken in the selection of food so that the necessary calories are provided by nutrient-dense foods. One of the best ways of providing these nutrients is by drinking additional milk each day or using appropriate substitutes. The extra milk will provide protein, calcium, phosphorus, thiamine, riboflavin, and niacin. If whole milk is used, it will also contribute saturated fat and cholesterol and provide 150 calories per 8 ounces of milk. Fat-free milk contributes no fat and provides 90 calories per 8-ounce serving and thus is the better choice. To be sure that the vitamin requirements of pregnancy are met, obstetricians, nurse midwives, and physician's assistants (PAs) may prescribe a prenatal vitamin supplement in addition to an iron supplement. However, it is not advisable for the mother to take any unprescribed nutrient supplement, as an excess of vitamins or minerals can be toxic to mother and infant. The unusual cravings for certain foods during pregnancy do no harm unless eating them interferes with the normal balanced diet or causes excessive weight gain. **CONCERNS DURING PREGNANCY** **NAUSEA** Sometimes nausea (the feeling of a need to vomit) occurs during the first trimester of pregnancy. This type of nausea is commonly known as morning sickness, but it can occur at any time. It typically passes as the pregnancy proceeds to the second trimester. The following suggestions can help relieve morning sickness: - Eat dry crackers or dry toast before rising. - Eat small, frequent meals. - Avoid foods with offensive odors. - Avoid liquids at mealtime. In rare cases, the nausea persists and becomes so severe that it is lifethreatening. This condition is called hyperemesis gravidarum. The mother may be hospitalized and given parenteral nutrition. This means the patient is given nutrients via a vein. Such cases are difficult, and the patients need emotional support and optimism from those who care for them. **CONSTIPATION** Constipation and hemorrhoids can be relieved by eating high-fiber foods, getting daily exercise, drinking at least 8 glasses of liquid each day, and responding immediately to the urge to defecate. **HEARTBURN** Heartburn can result from relaxation of the cardiac sphincter and smooth muscles related to progesterone. Heartburn is a common complaint during pregnancy. As the fetus grows, it pushes on the mother's stomach, which may cause stomach acid to move into the lower esophagus and create a burning sensation there. Heartburn may be relieved by eating small, frequent meals; avoiding spicy or greasy foods; avoiding liquids with meals; waiting at least an hour after eating before lying down; and waiting at least 2 hours before exercising. **EXCESSIVE WEIGHT GAIN** If weight gain becomes excessive, the pregnant woman should reevaluate her diet and eliminate foods (except for the extra pint of milk). Examples include candy, cookies, rich desserts, chips, salad dressings (other than fat free), and sweetened beverages. In addition, she might drink fat-free milk, if not doing so, which would reduce her calories but not her intake of proteins, vitamins, and minerals. Except in cases in which the woman cannot tolerate lactose (the sugar in milk), it is not advisable to substitute calcium pills for milk because the substitution reduces the protein, vitamin, and mineral content of the diet. A bowl of clean, crisp, raw vegetables such as broccoli or cauliflower tips, carrots, celery, cucumber, zucchini sticks, or radishes dipped in a fat-free salad dressing or salsa can provide interesting snacks that are nutritious, filling, satisfying, and low in calories. Fruits and custards made with fat-free milk make nutritious, satisfying desserts that are not high in calories. Broiling, baking, or boiling foods instead of frying can further reduce the caloric intake. **PREGNANCY-INDUCED HYPERTENSION** Pregnancy-induced hypertension (PIH) was formerly called toxemia or preeclampsia. It is a condition that sometimes occurs during the third trimester. It is characterized by high blood pressure, the presence of albumin the urine (proteinuria), and edema. The edema causes a somewhat sudden increase in weight. If the condition persists and reaches the eclamptic (convulsive) stage, convulsions, coma, and death of mother and child may occur. The cause of this condition is not known, but it occurs more frequently in first-time pregnancies, in multifetal pregnancies, in those women with morbid obesity, and among pregnant women on inadequate diets, especially protein-deficient diets. Pregnant adolescents have a higher rate of PIH than do pregnant adults. **PICA** Pica is the craving for nonfood substances such as starch, clay (soil), or ice. The reasons people get such a craving are not clear. Although both men and women are affected, pica is most common among pregnant women. Some believe it relieves nausea. Others think the practice is based on cultural heritage. The consumption of soil should be highly discouraged. Soil contains bacteria that would contaminate both mother and fetus. Ingesting soil can lead to an intestinal blockage, and substances in the soil would bind with minerals, preventing absorption by the body and thus leading to nutrient deficiencies. If any of the nonfood substances replaces nutrientrich foods in the diet, this will result in multiple nutrient deficiencies. Eating laundry starch, in addition to a regular diet, will add unneeded calories and carbohydrates. **ANEMIA** Anemia is a condition caused by an insufficiency of red blood cells, hemoglobin, or blood volume. The patient suffering from it does not receive sufficient oxygen from the blood and consequently feels weak and tired, has a poor appetite, and appears pale. Iron deficiency is its most common form. During pregnancy, the increased volume of blood creates the need for additional iron. When this need is not met by the diet or by the iron stores in the mother's body, iron deficiency anemia develops. This may be treated with a daily iron supplement. Folate deficiency can result in a form of megaloblastic anemia that can occur during pregnancy. It is characterized by too few red blood cells and by large immature red blood cells. The body's requirement for folic acid increases dramatically when new red blood cells are being formed. Consequently, the obstetrician might prescribe a folate supplement of 400 to 600 microgram a day during pregnancy. Alcohol, **CAFFEINE, DRUGS, AND TOBACCO** Alcohol consumption is associated with subnormal physical and mental development of the fetus. This is called fetal alcohol syndrome (FAS). Many infants with FAS are premature and have a low birth weight. Physical characteristics may include a small head, short eye slits that make eyes appear to be set far apart, a flat midface, and a thin upper lip. There is usually a growth deficiency (height, weight), placing the child in the lowest tenth of age norms. There is also evidence of central nervous system dysfunction, including hyperactivity, seizures, attention deficits, and microcephaly (small head). Another condition caused by ingesting alcohol while pregnant is fetal alcohol effect (FAE). Children with FAE are born with less dramatic or no physical defects but with many of the behavioral and psychosocial problems associated with FAS. Those with FAE are not able to lead normal lives due to deficits in intelligence and behavioral and social abilities. When the mother drinks alcohol, it enters the fetal bloodstream in the same concentration as it does the mother's. Unfortunately, the fetus does not have the capacity to metabolize it as quickly as the mother, so it stays longer in the fetal blood than it does in the maternal blood. Abstinence is recommended. Caffeine is known to cross the placenta, and it enters the fetal bloodstream. Birth defects in newborn rats whose mothers were fed very high doses of caffeine during pregnancy have been observed, but there are no data on humans showing that moderate amounts of caffeine are harmful. As a safety measure, however, it is suggested that pregnant women limit their caffeine intake to 2 cups of caffeine-containing beverages each day, or less than 300 mg/day. Drugs vary in their effects, but self-prescribed drugs, including vitamins and mineral supplements and dangerous illegal drugs, can all damage the fetus. Drugs derived from vitamin A can cause fetal malformations and spontaneous abortion. Illegal drugs can cause the infant to be born addicted to whatever substance the mother used and, possibly, to be born with the human immunodeficiency virus (HIV). If a pregnant woman is known to be infected with HIV, her physician may prescribe AZT in an attempt to prevent the spread of the disease to the developing fetus. Tobacco smoking by pregnant women has for some time been associated with babies of reduced birth weight. The more the mother smokes, the smaller her baby will be because smoking reduces the oxygen and nutrients carried by the blood. Other risks associated with smoking include SIDS (sudden infant death syndrome), fetal death, spontaneous abortion, and complications at birth. Smoking during pregnancy may also affect the intellectual and behavioral development of the baby as it grows up. Because the substances discussed in this section may cause fetal problems, it is advisable that pregnant women avoid them. **DIET FOR THE PREGNANT WOMAN WITH DIABETES** Diabetes mellitus is a group of diseases in which one cannot use or store glucose normally because of inadequate production or use of insulin. This impaired metabolism causes glucose to accumulate in the blood, where it causes numerous problems if not controlled. Some women have diabetes when they become pregnant. Others may develop gestational diabetes during pregnancy. In most cases, this latter type disappears after the infant is born; however, there is a 40% increased risk of developing type 2 diabetes later in life. Either type increases the risks of physical or mental defects in the infant, stillbirth, and macrosomia (birth weight over 9 pounds) unless blood glucose levels are carefully monitored and maintained within normal limits. Every pregnant woman should be tested for diabetes between 16 and 28 weeks of gestation. Those found to have the disease must learn to monitor their diets to maintain normal blood glucose levels and to avoid both hypoglycemia and hyperglycemia. In general, the nutrient requirements of the pregnant woman with diabetes are the same as for the normal pregnant woman. The diet should be planned with a registered dietitian or a certified diabetes educator because it will depend on the type of insulin and the time and number of injections. Clients with gestational diabetes and diabetic clients who do not normally require insulin to control their diabetes may require insulin during pregnancy to control blood glucose levels. Oral hypoglycemic agents have also been approved for use during pregnancy. Between-meal feedings help maintain blood glucose at a steady level. Artificial sweeteners have been researched extensively and found to be safe for use during pregnancy. **PREGNANCY DURING ADOLESCENCE** Teenage pregnancy is an increasing concern. The nutritional, physical, psychological, social, and economic demands on a pregnant adolescent are tremendous. With the birth of the infant, they increase. Young women who are themselves still in need of nurturing and financial support are suddenly responsible for helpless newborns. If the mother does not have sufficient help, the total effect on her and the child can be devastating. The young woman may need prenatal health care, infant care, and psychological, nutritional, and economic counseling, as well as help in locating appropriate housing. And at this time, the young woman's family may or may not be supportive. At such a time, nutritional habits can seem to some as being of slight importance. They are, however, of primary importance. An adolescent's eating habits may not be adequate to fulfill the nutritional needs of her own growing body. When she adds the nutritional burden of a developing fetus, both are put at risk. Adolescents are particularly vulnerable to pregnancy-induced hypertension and premature delivery. PIH can cause cardiovascular and kidney problems later. Premature delivery is a leading cause of death among newborns. Inadequate nutrition of the mother is related to both mental and physical birth defects. These young women will need to know their own nutritional needs and the additional nutritional requirements of pregnancy (see Table 11-2). The government-funded WIC (Women, Infants, and Children) program can help with prenatal care, nutrition education, and adequate food for the best outcome possible. Pregnant teenagers will need much counseling and emotional support from caring, experienced people before nutritional improvements can be suggested. **LACTATION** A woman needs to decide whether to breastfeed before her infant is born. Almost all women can breastfeed; breast size is no barrier. Lactation, the production and secretion of breast milk for the purpose of nourishing an infant, is facilitated by an interplay of various hormones after delivery of the infant. Oxytocin and prolactin instigate the lactation process. Prolactin is responsible for milk production, and oxytocin is involved in milk ejection from the breast. The infant's sucking initiates the release of oxytocin, which causes the ejection of milk into the infant's mouth. This is called the let-down reflex. It is a supply-and-demand mechanism. The more an infant nurses, the more milk the mother produces. It will take 2 to 3 weeks to fully establish a feeding routine; therefore, it is recommended that no supplemental feedings be given during this time. Human milk is formulated to meet the nutrient needs of infants for the first 6 months of life. Iron content in breast milk is very low, but it is very well absorbed; therefore, no iron supplement is needed for breastfed babies. **LACTATION SPECIALIST** A lactation specialist is an expert on breastfeeding and helps new mothers who may be having problems such as the baby not latching on properly. This could cause the breast to become sore and could be discouraging to first-time mothers. Since the best first food for babies is breast milk, a lactation specialist can teach the proper techniques for successful breastfeeding. **BENEFITS OF BREASTFEEDING** There are many positive reasons to breastfeed. The primary benefit of breast milk is nutritional. Breast milk contains just the right amount of lactose; water; essential fatty acids; and amino acids for brain development, growth, and digestion. No babies are allergic to their mother's milk, although they may have reactions to something their mother eats. Human milk contains at least 100 ingredients not found in formula. Breastfed babies have a lower incidence of ear infections, diarrhea, allergies, and hospital admissions. Breastfed babies receive immunities from their mothers for the diseases that the mother has had or has been exposed to. When a baby becomes ill, the bacteria causing the illness is transmitted to the mother while the baby is breastfeeding; the mother's immune system will start making antibodies for the baby. Sucking at the breast promotes good jaw development because it is harder work to get milk out of a breast than a bottle, and the exercise strengthens the jaws and encourages the growth of straight, healthy teeth. Breastfeeding facilitates bonding between mother and child. The skin-to-skin contact helps a baby feel safe, secure, and loved. Pediatricians encourage mothers of premature babies to hold their babies on their chests---skin to skin. This is called "kangaroo care," which has been shown to soothe and calm a baby and help maintain the baby's temperature. Fathers too can participate in kangaroo care by placing their infants against their bare chests. Benefits for mother include help in losing the pounds gained during pregnancy and stimulating the uterus to contract to its original size. Resting is important for a new mother, and breastfeeding gives her that opportunity. Breastfeeding is economical, always the right temperature, and readily available---especially in the middle of the night. There is no need to stop breastfeeding when returning to work; a breast pump can be used to express milk for feedings when the mother is not available. Breast milk will keep 8 to 10 hours at room temperature (66°--72°F), 8 days in the refrigerator, 3 to 4 months in the refrigerator freezer, and 12 months in a deep freezer. Previously frozen milk must be used within 24 hours after defrosting in the refrigerator. Breast milk should not be heated in the microwave or directly on the stove. Those methods of heating breast milk will kill its immune-enhancing ability. **CALORIE REQUIREMENTS DURING LACTATION** The mother's calorie requirement increases during lactation. The caloric requirement depends on the amount of milk produced. Approximately 85 calories are required to produce 100 ml (31 ⁄3 ounces) of milk. During the first 6 months, average daily milk production is 750 ml (25 ounces), and for this the mother requires approximately an extra 640 calories a day. During the second 6 months, when the baby begins to eat food in addition to breast milk, average daily milk production slows to 600 ml (20 ounces), and the caloric requirement is reduced to approximately 510 extra calories a day. The Food and Nutrition Board suggests an increase of 500 calories a day during lactation. This is less than the actual need because it is assumed that some fat has been stored during pregnancy and can be used for milk production. The precise number of calories the mother needs depends on the size of the infant and its appetite and on the size and activities of the mother. Each ounce of human milk contains 20 calories. If the mother's diet contains insufficient calories the quantity of milk can be reduced, as seen in many third world countries. Thus, lactation is not a good time to go on a strict weight loss diet. There will be some natural weight loss caused by the burning of the stored fat for milk production. **NUTRIENT REQUIREMENTS DURING LACTATION** In general, most nutrient requirements are increased during lactation. The amounts depend on the age of the mother (see Table 11-2). Protein is of particular importance because it is estimated that 10 grams of protein are secreted in the milk each day. She should be sure to include sufficient fruits and vegetables, especially those rich in vitamin C. Extra fat-free milk will provide many of the additional nutrients and calories required during lactation. Chips, sodas, candies, and desserts provide little more than calories. Vegetarians will need to be especially careful to be sure they have sufficient calories, iron, zinc, copper, protein, calcium, and vitamin D. A vitamin B12 supplement can be prescribed for them. It is important that the nursing mother have sufficient fluids to replace those lost in the infant's milk. Water and real fruit juice are the best choices. The mother should be made aware that she must reduce her caloric intake at the end of the nursing period to avoid adding unwanted weight. **MEDICINES, CAFFEINE, ALCOHOL, AND TOBACCO** Most chemicals enter the mother's milk, so it is essential that the mother check with her obstetrician before using any medicines or nutritional supplements. Caffeine can cause the infant to be irritable. Alcohol in excess, tobacco, and illegal drugs can be very harmful. Both illegal drugs, such as marijuana or heroin, and prescription medication, such as methadone and oxycodone, can cause the baby to be excessively drowsy and to feed poorly. Stimulant drugs can cause the baby to be irritable. The biggest concern is addiction of the mother and baby. **CONSIDERATIONS FOR THE HEALTH CARE PROFESSIONAL** Good nutrition during pregnancy can make the difference between a healthy, productive life and one shattered by health and economic problems---for both mother and child. Most pregnant women will want the best nutrition for themselves and their children. They also will be concerned about their weight during and after pregnancy. It is essential that they receive advice from a properly trained health care professional. Articles in newspapers and magazines or in pamphlets from health food stores may or may not be correct and should not be taken at face value unless approved by a professional in the dietetic field. Nutrition is currently a popular topic, and people are inclined to believe what is printed. It can be difficult to persuade people that the information they read is incorrect. As always, the health care professional must use great patience in reeducating those clients who may require it. The pregnant teenager can present the greatest challenge. Her needs are vast, but her experience, and thus her perspective, is limited. Teaching pregnant adolescents about good nutrition may be difficult but, if successful, can help not only that particular client but also her child and her friends. **DIET DURING INFANCY** Food and its presentation are extremely important during the baby's first year. Physical and mental development are dependent on the food itself, and psychosocial development is affected by the time and manner in which the food is offered. Infants react to their parents' emotions. If food is forced on a child or withheld until the child is uncomfortable or if the food is presented in a tense manner, the child reacts with tension and unhappiness. If the parent is relaxed, an infant's mealtime can be a pleasure for both parent and child. Although babies have been fed according to prescribed time schedules in the past, it is preferable to feed infants on demand. Feeding on demand prevents the frustrations that hunger can bring and helps the child develop trust in people. The newborn may require more frequent feedings, but normally the demand schedule averages approximately every 4 hours by the time the baby is 2 or 3 months old. **NUTRITIONAL REQUIREMENTS** The first year of life is a period of the most rapid growth in one's life. A baby doubles its birth weight by 6 months of age and triples it within the first year. This explains why the infant's energy, vitamin, mineral, and protein requirements are higher per unit of body weight than those of older children or adults. It is important to remember, however, that growth rates vary from child to child. Nutritional needs will depend largely on a child's growth rate. During the first year, the normal child needs 98 to 108 calories per kilogram of body weight each day. This is approximately two to three times the adult requirement. Low-birth-weight infants and infants who have suffered from malnutrition or illness require more than the normal number of calories per kilogram of body weight. The nutritional status of infants is reflected by many of the same characteristics as those of adults. The basis of the infant's diet is breast milk or formula. Either one is a highly nutritious, digestible food containing proteins, fats, carbohydrates, vitamins, minerals, and water. It is recommended that infants up to 6 months of age have 2.2 grams of protein per kilogram of weight each day, and from 6 to 12 months, 1.56 grams of protein per kilogram of weight each day. This is satisfactorily supplied by human milk or by infant formulas. Infants have more water per pound of body weight than do adults. Thus, they usually need 1.5 ml of water per calorie. This is the same ratio of water to calories as is found in human milk and in most infant formulas. Essential vitamins and minerals can be supplied in breast milk, formula, and food. Except for vitamin D, breast milk provides all the nutrients an infant needs for the first 4 to 6 months of life. An infant is born with a 3- to 6-month supply of iron. When the infant reaches 6 months of age, the pediatrician usually starts the infant on iron-fortified cereal. Human milk usually supplies the infant with sufficient vitamin C. Iron fortified formula is available, and its use is recommended by the American Academy of Pediatricians if the baby is not being breastfed. The pediatrician can prescribe a vitamin D supplement for infants who are nursed and who are not exposed to sunlight on a regular basis. Newborns lack intestinal bacteria to synthesize vitamin K, so they are routinely given a vitamin K supplement shortly after birth. In addition, some pediatricians prescribe fluoride for breastfed babies or for formula-fed babies living in areas where the water, such as well water, contains little fluoride. Care must be taken that infants do not receive excessive amounts of either vitamins A or D because both can be toxic in excessive amounts. Vitamin A can damage the liver and cause bone abnormalities, and vitamin D can damage the cardiovascular system and kidneys. **BREASTFEEDING** Although babies will thrive whether nursed or formula-fed, breastfeeding provides advantages that formulas cannot match. Breastfeeding is nature's way of providing a good diet for the baby. It is, in fact, used as the guide by which nutritional requirements of infants are measured. Mother's milk provides the infant with temporary immunity to many infectious diseases. It is economical, nutritionally perfect, and sanitary, and it saves time otherwise spent in shopping for or preparing formula. It is sterile, is easy to digest, and usually does not cause gastrointestinal disturbances or allergic reactions. Breastfed infants have fewer infections (especially ear infections) during the first few months of life than formula-fed babies. And because breast milk contains less protein and minerals than infant formula, it reduces the load on the infant's kidneys. Breastfeeding also promotes oral motor development in infants and decreases the infant's risk of obesity and diabetes. Within the first several weeks of life the infant will nurse approximately every 2--4 hours. As the infant grows and develops, a stronger sucking ability will allow more milk to be extracted at each feeding, and the frequency of nursing sessions will decrease. It is recommended that an infant nurse at each breast for approximately 10 to 15 minutes each session. Growth spurts occur at about 10 days, 2 weeks, 6 weeks, and 3 months. During this time, the infant will nurse more frequently to increase the supply of nutrients needed to support growth. One can be quite confident the infant is getting sufficient nutrients and calories from breastfeeding if (1) there are six or more wet diapers a day, (2) there is normal growth, (3) there are one or two mustard-colored bowel movements a day, and (4) the breast becomes less full during nursing. From the mother's perspective at least, the bonding that occurs during breastfeeding is unmatched. In addition, breastfeeding helps the mother's uterus return to normal size after delivery, controls postpartum bleeding, and also helps the mother more quickly return to her prepregnancy weight. Research has shown a correlation between breastfeeding and a decreased risk of breast cancer and osteoporosis in premenopausal women. Breastfeeding had been on the decline for many years, but a growing number of mothers are now nursing their babies. If the mother works and cannot be available for every feeding, breast milk can be expressed earlier, refrigerated or frozen, and used at the appropriate time, or a bottle of formula can be substituted. Never warm the breast milk in a microwave because the antibodies will be destroyed. **BOTTLE FEEDING** Many parents will choose to bottle-feed their babies. Some women fear they will be unable to produce enough breast milk. Some lack emotional support from their families, and some simply find breastfeeding foreign to their culture. Others who are employed or involved in many activities outside the home find bottle feeding more convenient. Either way of feeding is acceptable provided the infant is given love and attention during the feeding. The infant should be cuddled and held in a semi-upright position during the feeding. It appears that babies fed this way are less inclined to develop middle ear infections than those fed lying down. It is believed that the upright position prevents fluid from pooling at the back of the throat and entering tubes from the middle ear. During and after the feeding, the infant should be burped to release gas in the stomach, just as the breast-fed infant should be burped. Burping helps prevent regurgitation. If the baby is to be bottle-fed, the pediatrician will provide information on commercial formulas and feeding instructions. Formulas are usually based on cow's milk because it is abundant and easily modified to resemble human milk. It must be modified because it has more protein and mineral salts and less milk sugar (lactose) than human milk. Formulas, such as soy formula, are developed so that they are similar to human milk in nutrient and caloric values. When an infant is extremely sensitive or allergic to infant formulas, a synthetic formula may be given. Synthetic milk is commonly made from soybeans. Formulas with predigested proteins are used for infants unable to tolerate all other types of formulas. Formulas can be purchased in ready-to-feed, concentrated, or powdered forms. Sterile or boiled tap water must be mixed with the concentrated and powdered forms. The most convenient type is also the most expensive. If the type purchased requires the addition of water, it is essential that the amount of water added be correctly measured. Too little water will create too heavy a protein and mineral load for the infant's kidneys. Too much water will dilute the nutrient and calorie value so that the infant will not thrive, and also it could lead to brain edema or seizures. Infants under the age of 1 year should not be given regular cow's milk. Because its protein is more difficult and slower to digest than that of human milk, it can cause gastrointestinal blood loss. The kidneys are challenged by its high protein and mineral content, and dehydration and even damage to the central nervous system can result. In addition, the fat is less bioavailable, meaning it is not absorbed as efficiently as that in human milk. Formula may be given cold, at room temperature, or warmed, but it should be given at the same temperature consistently. To warm the formula for feeding, place the bottle in a saucepan of warm water or a bottle warmer. The bottles should be shaken occasionally to warm the contents evenly. Warming the bottle in the microwave is not advisable because milk can heat unevenly and burn the infant's mouth. The temperature of the milk can be tested by shaking a few drops on one's wrist. The milk should feel lukewarm. Infants should not be put to bed with a bottle. Saliva, which normally cleanses the teeth, diminishes as the infant falls asleep. The milk then bathes the upper front teeth, causing tooth decay. Also, the bottle can cause the upper jaw to protrude and the lower to recede. The result is known as the baby bottle mouth or nursing bottle syndrome. It is preferable to feed the infant the bedtime bottle, cleanse the teeth and gums with some water from another bottle or cup, and then put the infant to bed. **SUPPLEMENTARY FOODS** The age at which infants are introduced to solid and semi-solid food has varied considerably over the years. At the beginning of the last century, doctors advocated that children be fed only breast milk during their first 12 months. By the 1950s, in response to parental demand, some pediatricians advised the introduction of solid food before the age of 1 month. Now, the general recommendation is that the infant's diet be limited to breast milk or formula until the age of 4 to 6 months and that breast milk or formula remain the major food source until the child is 1 year old. With the appropriate supplements of iron and vitamin D and possibly vitamin C and fluoride, breast milk or formula fulfills the nutritional requirements of most children until they reach the age of 6 months. The introduction of solid foods before the age of 4 to 6 months is not recommended. The child's gastrointestinal tract and kidneys are not sufficiently developed to handle solid food before that age. Further, it is thought that the early introduction of solid foods may increase the likelihood of overfeeding and the possibility of the development of food allergies, particularly in children whose parents suffer from allergies. An infant's readiness for solid foods will be demonstrated by (1) the physical ability to pull food into the mouth rather than always pushing the tongue and food out of the mouth (extrusion reflex disappears by 4--6 months), (2) a willingness to participate in the process, (3) the ability to sit up with support, (4) having head and neck control, and (5) the need for additional nutrients. If the infant is drinking more than 32 ounces of formula or nursing 8 to 10 times in 24 hours and is at least 4 months old, then solid food should be started. Solid foods must be introduced gradually and individually. One food is introduced and then no other new food for 4 or 5 days. If there is no allergic reaction, another food can be introduced, a waiting period allowed, then another, and so on. The typical order of introduction begins with cereal, usually iron-fortified rice, then oat, wheat, and mixed cereals. Cooked and pureed vegetables follow, then cooked and pureed fruits, egg yolk, and, finally, finely ground meats. Between 6 and 12 months, toast, zwieback, teething biscuits, and Cheerios can be added in small amounts. Honey should never be given to an infant because it could be contaminated with Clostridium botulinum bacteria. When the infant learns to drink from a cup, juice can be introduced. Juice should never be given from a bottle because babies will fill up on it and not get enough calories from other sources. Pasteurized apple juice is usually given first. It is recommended that only 4 ounces per day of 100% juice products be given because they are nutrient-dense. Babies differ in the amount of food they eat from day to day. An infant will let you know when he or she is full by the following: - Playing with the nipple on a bottle or a breast - Looking around and no longer opening his or her mouth to solid food - Falling asleep while eating - Playing with food and not eating Adults may try to overfeed infants when solid food is introduced. The guidelines in Table 12-1 may be helpful. By the age of 1 year, most babies are eating foods from all of the food groups and may have most any food that is easily chewed and digested. However, precautions must be taken to avoid offering foods on which the child can choke. Examples include hotdogs, nuts, whole peas, grapes, popcorn, small candies, and small pieces of tough meat or raw vegetables. Foods should be selected according to the advice of the health care provider or pediatrician. It is not necessary to use the commercially prepared "third" foods. Table foods generally can be used, though they may need to first be mashed or run through a blender. MyPyramid provides excellent help in determining the baby's menu. Its use will help supply the appropriate nutrients and develop good eating habits. It is particularly important at this time to avoid excess sugar and salt in the infant's diet so that the child does not develop a taste for them and, consequently, overuse them throughout life. Weaning actually begins when the infant is first given food from a spoon. It progresses as the child shows an interest in and an ability to drink from a cup. The child will ultimately discard the bottle or refuse the breast. If the child shows great reluctance to discard the bottle or still seeks the breast, the parents should be patient and discuss this with their health care provider. **SPECIAL CONSIDERATIONS FOR INFANTS WITH ALTERED NUTRITIONAL NEEDS** Premature Infants An infant born before 37 weeks gestation is considered to be premature. These babies have special needs. The sucking reflex is not developed until 34 weeks gestation, and infants born earlier must be fed by total parenteral nutrition, tube feedings, or bolus feedings. The best food for a premature infant is its mother's breast milk, which contains more protein, sodium, immunologic properties, and some other minerals than does the milk produced by mothers of full-term infants. Other concerns in preterm infants are low birth weight, underdeveloped lungs, immature GI tract, inadequate bone mineralization, and lack of fat reserves. Many specialized formulas are available for premature infants, but breast milk is best because its composition is made just for the baby, and it changes according to the baby's needs. Mothers of premature babies should be encouraged to pump their milk until the infant is able to nurse. **CYSTIC FIBROSIS** Cystic fibrosis (CF) is an inherited disease. CF causes the body to produce abnormally thick, sticky secretions (mucus) within cells lining organs such as the lungs and pancreas. The thick mucus also obstructs the pancreas, preventing enzymes from reaching the intestines to help break down and digest food. Eighty-five percent of CF children have exocrine pancreatic insufficiency (PI) and are at nutritional risk due to decreased production of digestive enzymes. Malabsorption of fat is also associated with CF; therefore, the recommendation is 35% to 40% of total calorie intake to be fat. Digestive enzymes are taken in capsule form when food is eaten, and supplementation of fat-soluble vitamins should also be done at mealtime. There is also a water-miscible form of fat- soluble vitamins that can be administered if normal levels cannot be maintained with the use of only fat-soluble vitamins. It is not unusual for those having CF to be malnourished, even with supplementation, due to malabsorption of nutrients and increased needs. One possible solution would be nighttime tube feedings to supplement oral intake if adequate nutrition and weight cannot be maintained. **FAILURE TO THRIVE** Failure to thrive (FTT) can be determined by plotting the infant's growth on standardized growth charts (Figure 12-10); consideration must be made for genetic and ethnic variations. Weight for height is the first parameter affected when determining FTT. Later, height and head circumference are affected. Other signs might be slow development or lack of physical skills such as rolling over, sitting, standing, and walking. Mental and social skills will also be delayed. Babies grow the most in the first 6 months of life, and this is when their brain undergoes crucial development, which can affect the rest of their lives. Failure to thrive can have many causes, such as watered-down formula, congenital abnormalities, AIDS, lack of bonding, child abuse, or neglect. **SPECIAL CONSIDERATIONS FOR INFANTS WITH METABOLIC DISORDERS** Some infants are born with the inability to metabolize specific nutrients. These congenital disabilities are called inborn errors of metabolism. They are caused by mutations in the genes. There is great variation in the seriousness of the conditions caused by these defects. Some cause death at an early age, and some can be minimized so that life can be supported by adjustments in the normal diet. Among children born with these defects, there is, however, the common danger of damage to the central nervous system because of their abnormal body chemistry. This results in mental retardation and sometimes retarded growth. Early diagnosis of these inborn errors, combined with diet therapy, increases the chances of preventing retardation. Hospitals test newborns for some of these disorders as a matter of course. If there is a family history of a certain genetic disorder, genetic screening can be done. In addition, some of these abnormalities can be discovered by amniocentesis. **GALACTOSEMIA** Galactosemia is a condition, affecting 1 in 30,000 live births, in which there is a lack of the liver enzyme transferase. Transferase normally converts galactose to glucose. Galactose is the simple sugar resulting from the digestion of lactose, the sugar found in milk. When transferase is missing and the infant ingests anything containing galactose, the amount of galactose in the blood becomes so excessive that it is toxic. The newborn suffers diarrhea, vomiting, and edema, and the child's liver does not function normally. Cataracts may develop, galactosuria occurs, and mental retardation ensues. **DIET THERAPY** Diet therapy for galactosemia is the exclusion of anything containing milk from any mammal. During infancy, the treatment is relatively simple because parents can feed the baby lactose-free, commercially prepared formula and can provide supplemental minerals and vitamins. As the child grows and moves on to adult foods, parents must be extremely careful to avoid any food, beverage, or medicine that contains lactose. Nutritional supplements of calcium, vitamin D, and riboflavin must be given so that the diet is nutritionally adequate. This restricted diet may be necessary throughout life, but some physicians allow a somewhat liberalized diet as the child reaches school age. This may mean only small amounts of baked or processed foods that contain small amounts of milk. Even this restricted diet must be accompanied by careful and regular monitoring for galactosuria. **PHENYLKETONURIA (PKU)** In phenylketonuria (PKU), infants lack the liver enzyme phenylalanine hydroxylase, which is necessary for the metabolism of the amino acid phenylalanine. Infants seem to be normal at birth, but if the disease is not treated, most of them become hyperactive, suffer seizures between 6 and 18 months, and become mentally retarded. Public health law requires most hospitals today to screen newborns for phenylketonuria. PKU babies typically have light-colored skin and hair. Diet Therapy. There is a special, nutritionally adequate, commercial infant formula available for PKU babies. It is called Lofenalac. It has had 95% of phenylalanine removed from its protein source. It provides just enough phenylalanine for basic needs but no excess. The specific amount depends on the infant's size and growth rate. Regular blood tests determine the adequacy of the amounts. Diets are carefully monitored for calorie and nutrient content and are adjusted frequently as needs change. Except for fats and sugars, there is some protein in all foods. Some of that protein is phenylalanine, so diets for the growing child eating normal food must be carefully planned. There are two varieties of synthetic milk available for older children. They are Phenyl-free and PKU-1, -2, or -3. None of these contains any phenylalanine. They can be used as beverages or in puddings and baked products. Diets should be monitored throughout life to avoid mental retardation and to control hyperactivity and aggressive behavior (Table 12-2). **MAPLE SYRUP URINE DISEASE (MSUD)** Maple syrup urine disease (MSUD) is a congenital defect resulting in the inability to metabolize three amino acids: leucine, isoleucine, and valine. It is named for the odor of the urine of these infants and affects 1 in 100,000 to 300,000 live births. When the infant ingests food protein, there are increased blood levels of these amino acids, causing ketosis. Hypoglycemia, apathy, and convulsions occur very early. Depending on the extent of the disease, if not treated promptly, the child can die from acidosis. Mild forms of the disease, if left untreated, will cause mental retardation and bouts of acidosis. **DIET THERAPY** The diet must provide sufficient calories and nutrients but with extremely restricted amounts of leucine, isoleucine, and valine. A special formula and low-protein foods are used. Diet therapy appears to be necessary throughout life. **CONSIDERATIONS FOR THE HEALTH CARE PROFESSIONAL** Although the physical and mental development of infants depends on the nutrients and calories they receive, their psychosocial development depends on how and when these nutrients and calories are provided. Some new parents will have a solid knowledge of the nutrition information needed but lack a real understanding of the importance of how and when food should be presented to infants. They may hold the infant during feedings but focus instead on the television or newspaper. Other parents may know instinctively how important cuddling and attention are to an infant, but they lack accurate knowledge of infant nutrition. Parents from both groups are apt to have opinions that may or may not be correct. The health care professional will help these parents most by listening carefully to them. The parents are more inclined to listen to advice when a two-way discussion follows. **DIET DURING CHILDHOOD AND ADOLESCENCE** 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. **CHILDREN AGES 1 TO 12** Eating habits develop during childhood. Once developed, poor eating habits will be difficult to change. They can exacerbate emotional and physical problems such as irritability, depression, anxiety, fatigue, and illness. Because children learn partly by imitation, learning good eating habits is easier if the parents have good habits and are calm and relaxed about the child's. Nutritious foods should be available at snack time as well as at mealtime, and meals should include a wide variety of foods to ensure good nutrient intake. Parents should be aware that it is not uncommon for children's appetites to vary. The rate of growth is not constant. As the child ages, the rate of growth actually slows. The approximate weight gain of a child during the second year of life is only 5 pounds. In addition, children's attention is increasingly focused on their environment rather than their stomachs. Consequently, their appetites and interest in food commonly decrease during the early years. Children between the ages of 1 and 3 undergo vast changes. Their legs grow longer, they develop muscles, they lose their baby shape, they begin to walk and talk, and they learn to feed and generally assert themselves. A 2-year-old child's statement "No!" is his or her way of saying "Let me decide!" As children continue to grow and develop, they will increasingly and healthfully assert themselves. They want and need to show their growing independence. Parents should respect this need as much as possible. Children's likes and dislikes may change. New foods should be introduced gradually, in small amounts, and as attractively as possible. Allowing the child to assist in purchasing and preparing a new food is often a good way of arousing interest in the food and a desire to eat it. Children should be offered nutrient-dense foods because the amount eaten often will be small. Fats should not be limited before the age of 2 years, but meals and snacks should not be fat-laden either. Whole milk is recommended until the age of 2, but low-fat or fat-free should be served from 2 on. The guideline for fat intake is 30% to 35% of calories from fat for 2- to 3-year-olds and 25% to 35% of calories from fat for 4- to 18-year-olds, with no more than 7% from saturated fats. It is recommended that children not salt their food at the table or have foods prepared with a lot of salt. Young children are especially sensitive to and reject hot (temperature) foods, but they like crisp textures, mild flavors, and familiar foods. They are wary of foods covered by sauce or gravy. Parents should set realistic goals and expectations about the amount of food a child needs. A good rule of thumb for preschool children is 1 tablespoon for each year of age. Table 13-1 details serving sizes according to age. Calorie needs will depend on rate of growth, activity level, body size, metabolism, and health. Children can have food jags, such as eating only one or two foods, or rituals, such as not letting foods touch on the plate or using a different spoon for each food eaten. Choking is prevalent in young children. To prevent choking, do not give children under 4 years of age peanuts, grapes, hotdogs, raw carrots, hard candy, or thick peanut butter. A child needs a snack every 2 to 3 hours for continued energy. Children often prefer finger foods for snacks. Snacks should be nutrient-dense and as nutritious as food served at mealtime. Cheese, Cheerios, fruit, milk, and unsweetened cereals make good snacks. Mealtime should be pleasant, and food should not be forced on the child. The parent's primary responsibility is to provide nutritious food in a pleasant setting, and the child's responsibility is to decide how much food to eat or whether to eat, according to child expert Ellyn Satter (1995). When a child is hungry, he or she will eat. Forcing a child to eat can cause disordered eating and, ultimately, chronic overeating, anorexia nervosa, or bulimia. **CALORIE AND NUTRIENT NEEDS** The rate of growth diminishes from the age of 1 until about 10; thus, the caloric requirement per pound of body weight also diminishes during this period. For example, at 6 months, a girl needs about 54 calories per pound of body weight, but by the age of 10, she will require only 35 calories per pound of body weight. Nutrient needs, however, do not diminish. From the age of 6 months to 10 years, nutrient needs actually increase because of the increase in body size. Therefore, it is especially important that young children are given nutritious foods that they will eat. A variety of foods should be offered, and, when possible, the child should be offered some choices of foods. Such a choice at the table helps the child's psychosocial development. In general, the young child will need 2 to 3 cups of low-fat or fat-free milk each day, or the equivalent in terms of calcium. However, excessive use of milk should be avoided because it can crowd out other iron-rich foods and possibly cause iron deficiency. The selections of the other food groups are the same for adults, but the portions will be smaller. The use of sweets should be minimized because the child is apt to prefer them to nutrient rich foods. Sweetened fruit juices, especially, should be limited. Children also need water and fiber in their diets. They need to drink 1 ml of water for each calorie. If food valued at 1,200 calories is eaten, then five 8-ounce glasses of water are needed. Fiber needs are calculated according to age. After age 3, a child's fiber needs are "age + 5 grams" and no more than "age + 10 grams." A child who eats more fiber than that might be too full to eat enough other foods to provide all the calories needed for growth and development. Fiber should be added slowly, if not already in the diet, and fluids must also be increased. Childhood is a good time to develop the lifelong good habit of getting enough dietary fiber to prevent constipation and diseases such as colon cancer and diverticulitis. Childhood Obesity Normal stature and weight for children can be determined using standardized growth charts. Expected growth patterns will fall between the 5th and 95th percentile; children whose weight falls outside those parameters need special evaluation and attention. Childhood obesity has become an epidemic. Overweight has doubled in the last 20 to 30 years, and one in five children is now overweight. The definition of overweight is a child at or above the 95th percentile of body mass index (BMI) by sex and age. Children are considered obese when their body fat exceeds lean muscle mass. Type 2 diabetes mellitus, rarely seen before in children, is now being diagnosed in children as young as 10; it is related to diet and weight. Childhood obesity is the result of an imbalance between the calories a child consumes as food and beverages and the calories a child expends for normal growth and development, metabolism, and physical activity. The bottom line is that calories eaten and calories expended must be balanced. There is no single factor that causes childhood obesity. An imbalance can result from the influences and interactions of a number of factors, including genetic, behavioral, and environmental. Genetics cannot be solely to blame for childhood obesity. The genetic factors of the population have not changed in the past 30 years, but the prevalence of overweight and obese children has tripled during this time. If one parent is obese, there is a 50% chance that their children will be obese. If both parents are obese, the risk increases to 80%. Certain behavioral factors can contribute to an energy imbalance and therefore obesity. Energy intake of large portions of food and beverages, eating meals away from home, frequent snacking on energy-dense foods, and consuming beverages with sugar are all contributing factors for obesity. Children drinking sugared beverages may not compensate for these additional calories at mealtime. Physical activity is important for children to help burn excess calories eaten. Obese children and adults have similar health problems. Physical activity will help increase bone strength and decrease blood pressure and prevent type 2 diabetes, sleep apnea, and hyperlipidemia. Many schools have discontinued physical education, especially for adolescents, but recess still continues for younger children. GET MOVING! Obese children have an 85% chance of being obese adults if they are obese after the age of 10. Physical activity can be as easy as walking for 60 minutes per day. Many children with working parents are not allowed to leave the house after returning from school. Sedentary activities, such as watching TV and DVDs, playing computer games and handheld electronic games, and eating, become the norm. There is a high correlation between watching TV and obesity. TV can contribute to poor food choices, excess snacking, and low metabolism. Environmental factors, including the home, child care, school, and community, can influence a child's behavior related to food and physical activity. In the home, children will imitate their parents in many ways, including eating habits and physical activity. Child care is an important place where healthy eating and physical activity habits can be developed. Approximately 80% of children with working mothers spend 15 to 40 hours per week at day care. Parents need to check the menu and activity schedule on a weekly basis. Children ages 5 to 17 are enrolled in school, which is a positive environment in which to teach healthy eating and the importance of physical activity. Unfortunately, the government is not helping, and many of the foods served in school cafeterias are government subsidies. They are generally highcalorie, high-fat foods that must be deep fried before serving. Butter and cheese sometimes are included in these subsides. Vending machines are in many schools and, if not stocked with healthy foods, can contribute to obesity. Leaders in the community must create an infrastructure conducive to physical activity like sidewalks, safe bike and walking trails, parks in neighborhoods, and a safe environment in which to participate. Snacking and portion control seem to be big issues with obese children. All foods can be fattening if eaten beyond needs. Children should not be put on a "diet." Children continue to grow, so if weight can be maintained by exercise and portion control until growth catches up, the problem of obesity will no longer exist. An obese child, like a child of normal weight, may need a snack after school. Make that snack a healthy choice, such as a medium-sized piece of fruit, vegetables (using salsa or fat-free ranch dressing as a dip), a 100-calorie bag of microwave popcorn, or a single serving of cereal. Single-serving-size bags or premeasured portion controlled snacks are ideal because an obese child will be likely to overeat when eating from a large bag. Help children avoid drinking their daily caloric needs with pop (soda) or other sweetened drinks. If junk food and sweetened drinks are not purchased, they cannot be consumed. What can parents do to help their children? Talk to a dietitian or a nurse for some ideas like the following: - Understand that this is a family problem and that the entire family will be involved in the solution. - Help your family balance their calories. One part of balancing is to supply adequate nutrition and help everyone develop healthy eating habits. - Develop healthy eating habits by doing the following: - Provide plenty of vegetables, fruits, and whole-grain products. - Include low-fat or nonfat dairy products. - Choose lean meats, poultry, fish, lentils, and dried beans for protein. - Serve correct portions. - Encourage everyone to drink lots of water. - Limit sugar-sweetened beverages. - Limit consumption of sugar and saturated fat. - Learn to make favorite dishes healthier. For new ideas about adding fruits and vegetables to your family's diet. - Remove calorie-rich temptations. Allow your children to eat them "sometimes" so that they will be truly a treat. Remember that small changes every day can lead to success. To continue the progress made with healthy eating, everyone must participate in one or more forms of physical activity each day for 60 minutes, such as the following: - Brisk walking - Playing tag - Jumping rope - Playing soccer - Basketball - Swimming - Riding Bicycles - Dancing In addition to encouraging physical activity, help children avoid too much sedentary time. Quiet time for homework and reading is fine. Obese children and adolescents are targets of social discrimination. This begins early in a child's school career, and the psychological effect can be devastating, causing low self-esteem, which in turn may hinder academic and social functioning. This may seem like a monumental task for parents, but it is well worth it. Not only will their children change their eating habits and start a lifelong exercise program, but so will they. **What Can Parents Do to Help?** - Provide only healthy, nourishing food for meals and snacks. If it is not available a child cannot eat it. - Limit TV and computer time. Remove TV sets from your child's bedroom. - Get moving yourself. Exercise benefits everyone. - Never tell a child he cannot have a food because "he is too fat." - Learn correct portions, even if this means weighing and measuring (see Table 13-1). - Remember, there is nothing a child cannot eat; it is just how often and how much will be consumed of a particular food. There are no good or bad foods. - Never provide food for comfort or as a reward. - Eat only at the table and at designated times. - Give water to drink rather than calorie-laden fruit juice. If a child won't drink water, then a small amount of juice can be mixed with water to give flavor. Use 1 4⁄ cup juice to 8--12 ounces of water. This glass of water-juice will contain about 30 calories versus 120--180 for 100% juice. - Eat slowly---it takes 20 minutes for the brain to get the message that the stomach is full. Make it a game---set a timer and see who can make the meal last for 20 minutes. - Use the 20-minutes technique if your child wants a calorie-dense snack such as cookies, chocolate, candy bars, or other calorie-dense foods. The child must set the timer, sit at the table with a portion controlled serving, pay attention to the treat, and make it last for 20 minutes. Holding it in the mouth and rolling it around on the tongue will satisfy taste buds quicker than swallowing immediately and may contribute to satiety sooner. - Learn to determine whether your child is really hungry or just bored, tired, or lonely. It takes 3 to 4 hours for a stomach to completely empty after a significant meal, so if that amount of time has elapsed, then your child is truly hungry. - Make sure your child gets enough sleep (8--10 hours per night), as sleep deprivation has been linked to obesity. - Change any unhealthy habits you may possess. You are your child's teacher. Preventing and reversing childhood obesity will also decrease the incidence of obesity-linked type 2 diabetes. **Childhood Type 2 Diabetes** As a result of the increase of childhood obesity, there is a parallel increase in diabetes, particularly type 2. Type 2 diabetes is normally found only in adults, usually after the age of 40, and is associated with weight. Most obese children will develop type 2 diabetes between the ages of 10 and 14. Children with type 2 diabetes should see a certified diabetes educator to learn what to eat to control their diabetes. The diabetes educator will also prescribe daily exercise and attention to fiber intake, both of which help control blood glucose. Increasing nutrition and exercise knowledge of parents and children appears to be the only way to prevent obesity and childhood type 2 diabetes. **Osteoporosis and Cardiovascular Disease** Children and adolescents live in the moment. This creates problems associated with osteoporosis and cardiovascular diseases. Adherence to sound nutrition principles during childhood and adolescence are needed to protect the heart and bones. Calcium must be consumed at the DRI level until the age of 30. Fat intake should follow the American Heart Association recommendations of 7% saturated fat, 8% polyunsaturated fat, and 15% monounsaturated fat while keeping total fat to 35% of daily calories. The typical diet of a teenager contains too much saturated fat and soda and not enough milk. These habits lead to adult health problems. Motivating children and teens to change their habits will be a challenge but needs to be done. **ADOLESCENTS** In general, a person between the ages of 13 and 20 is considered an adolescent. Adolescence is a period of rapid growth that causes major changes. It tends to begin between the ages of 10 and 13 in girls and between 13 and 16 in boys. The growth rate may be 3 inches a year for girls and 4 inches for boys. Bones grow and gain density, muscle and fat tissue develop, and blood volume increases. Sexual maturity occurs. Boys' voices change, girls experience the onset of menses, and both may experience acne. Acne is not caused by specific foods but by overactivity of the sebaceous glands of the skin. These changes are obvious and have a tremendous effect on an adolescent's psychosocial development. No two individuals will develop in the same way. One girl may become heavier than she might like, another may be thin, a boy may not develop the muscle or the height he desires, and some may develop serious complexion problems. It can be a time of great joy, but it also can be a time when counseling is needed. **Food Habits** Adolescents, especially boys, typically have enormous appetites. When good eating habits have been established during childhood and there is nutritious food available, the teenager's food habits should present no serious problem. Adolescents are imitators, like children, but instead of imitating adults, adolescents prefer to imitate their peers and do what is popular. Unfortunately, the foods that are popular often have low nutrient density such as potato chips, sodas, and candy. These foods provide mainly carbohydrates and fats and very little protein, vitamins, and minerals, except for salt, which is usually provided in excess. Adolescents' eating habits can be seriously affected by busy schedules, part-time jobs, athletics, social activities, and the lack of an available adult to prepare nutritious food when adolescents are hungry or have time to eat. When the adolescent's food habits need improvement, it is wise for the adult to tactfully inform her or him of nutritional needs and of the poor nutrition quality of the foods she or he is eating. The adolescent has a natural desire for independence and may resent being told what to do. Before attempting to change an adolescent's food habits, carefully check her or his food choices for nutrient content. It is too easily assumed that because the adolescent chooses the food, the food is automatically a poor choice in regard to nutrient content. It might be a good choice. An adolescent who has a problem maintaining an appropriate weight may need some advice regarding diet. **Calorie and Nutrient Needs** Because of adolescents' rapid growth, calorie requirements naturally increase. Boys' calorie requirements tend to be greater than girls' because boys are generally bigger, tend to be more physically active, and have more lean muscle mass than do girls. Except for vitamin D, nutrient needs increase dramatically at the onset of adolescence. Because of menstruation, girls have a greater need for iron than do boys. The DRIs for vitamin D, vitamin C, vitamin B12, calcium, phosphorus, and iodine are the same for both sexes. The DRIs for the remaining nutrients are higher for boys than they are for girls. **SPECIAL CONSIDERATIONS FOR THE ADOLESCENT RELATED TO NUTRITION CONCERNS** Adolescence is a stressful time for most young people. They are unexpectedly faced with numerous physical changes, an innate need for independence, increased work and extracurricular demands at school, in many cases jobs, and social and sexual pressures from their peers. For many teens, such stress can cause one or more of the following problems. **Anorexia Nervosa** In general, adolescent boys in the United States are considered well nourished. Studies show, however, that girls sometimes have diets deficient in calories and protein, iron, calcium, vitamin A, or some of the B vitamins. These deficiencies can be due to poor eating habits caused by concern about weight. A moderate concern about weight is understandable and possibly even beneficial, provided it does not cause diets to be deficient in essential nutrients or lead to a potentially fatal condition called anorexia nervosa. Anorexia nervosa, commonly called anorexia, is a psychological disorder more common to women than men. It can begin as early as late childhood, but usually begins during the teen years or the early twenties. It causes the client to drastically reduce calories, causing altered metabolism, which results in hair loss, low blood pressure, weakness, amenorrhea, brain damage, and even death. The causes of anorexia are unclear. Someone with this disorder (an anorexic) has an inordinate fear of being fat. Some anorexics have been overweight and have irrational fears of regaining lost weight. Some young women with demanding parents perceive this as their only means of control. Some may want to resemble slim fashion models and have a distorted body image, where they see themselves as fat even though they are extremely thin. Some fear growing up. Many are perfectionistic overachievers who want to control their body. It pleases them to deny themselves food when they are hungry. These young women usually set a maximum weight for themselves and become an expert at "counting calories" to maintain their chosen weight. They also often exercise excessively to control or reduce their weight. If the weight declines too far, the anorexic will ultimately die. Treatment requires the following: 1\. Development of a strong and trusting relationship between the client and the health care professionals involved in the case. 2\. That the client learn and accept that weight gain and a change in body contours are normal during adolescence. 3\. Nutritional therapy so the client will understand the need for both nutrients and calories and how best to obtain them. 4\. Individual and family counseling so the problem is understood by everyone. 5\. Close supervision by the health care professional. 6\. Time and patience from all involved. **Bulimia** Bulimia is a syndrome in which the client alternately binges and purges by inducing vomiting and using laxatives and diuretics to get rid of ingested food. Bulimics are said to fear that they cannot stop eating. They tend to be high achievers who are perfectionistic, obsessive, and depressed. They generally lack a strong sense of self and have a need to seem special. They know their binge--purge syndrome is abnormal but also fear being overweight. This condition is more common among women than men and can begin any time from the late teens into the thirties. A bulimic usually binges on high-calorie foods such as cookies, ice cream, pastries, and other "forbidden" foods. The binge can take only a few moments or can run several hours---until there is no space for more food. It occurs when the person is alone. Bulimia can follow a period of excessive dieting, and stress usually increases the frequency of binges. Bulimia is not usually life-threatening, but it can irritate the esophagus and cause electrolyte imbalances, malnutrition, dehydration, and dental caries. Treatment usually includes limiting eating to mealtimes, portion control, and close supervision after meals to prevent self-induced vomiting. Diet therapy helps teach the client basic nutritional facts so that he or she will be more inclined to treat the body with respect. Psychological counseling will help the client to understand his or her fears about food. Group therapy also can be helpful. Both bulimia and anorexia can be problems that will have to be confronted throughout the client's life. **Overweight** Being overweight during adolescence is particularly unfortunate because it is apt to diminish the individual's self-esteem and, consequently, can exclude her or him from the normal social life of the teen years, further diminishing self-esteem. Also, it tends to make the individual prone to overweight as an adult. Although numerous studies have been done, the cause of being overweight is difficult to determine. Heredity is believed to play a role. Just as one inherits height, color of hair, or artistic talents, it appears that one may inherit the tendency (or lack of it) to be overweight. Overfeeding during infancy and childhood also can be a contributing factor. Then, once a person is overweight, the overweight itself contributes further to the problem. For example, if a teenager becomes the center of his classmates' jokes, he or she may prefer to spend time alone, perhaps watching television and finding comfort in food. This behavior adds more calories, reduces activity, and, thus, worsens the condition. The problem of being overweight during adolescence is especially difficult to solve until the individual involved makes the independent decision to change lifestyle habits. After making such a decision, the teenager should see a physician to ensure that his or her health is good. The health care provider can play an important role by offering guidance on changing eating habits, increasing exercise, and adopting a healthier lifestyle. **Fast Foods** Many people have become extremely fond of fast foods. Many others are highly critical of their nutrient content. Examples of these foods---most of which are favorites of teenagers---include hamburgers, cheeseburgers, French fries, milkshakes, pizza, sodas, tacos, chili, fried chicken, and onion rings. Many fast-food companies have the nutrient content of their products available to help the public make better choices. Generally speaking, fast foods are excessively high in fat and sodium, as well as calories, and contain only limited amounts of vitamins and minerals (other than sodium) and little fiber. In Table 13-2, the nutrient content of some varieties of fast foods are shown compared with the DRIs for a 16-year-old girl. This shows the potential for problems with a diet that regularly consists of these foods to the exclusion of others. Nevertheless, these foods are more nutritious than sodas, cakes, and candy. When used with discretion in a balanced diet, they are not harmful. However, teens often use fast foods as a snack to hold them over until dinner, and this results in consumption of many extra calories. **Alcohol** In a process called fermentation, sugars and starches can be changed to alcohol. Enzyme action causes this change. Alcohol is typically made from fruit, corn, rye, barley, rice, or potatoes. It provides 7 calories per gram but almost no nutrients. Alcohol is a substance that can have serious side effects. Initially, it causes the drinker to feel "happy" because it lowers inhibitions. This feeling affects the drinker's judgment and can lead to accidents and crime. Ultimately, alcohol is a depressant; continued drinking leads to sleepiness, loss of consciousness, and, when too much is consumed in a short period, death. Abuse (overuse) of alcohol is called alcoholism. Alcoholism can destroy the lives of families and devastate the drinker's nutritional status and thus health. It affects absorption and normal metabolism of glucose, fats, proteins, and vitamins. When thiamine and niacin cannot be absorbed, the cells cannot use glucose for energy. Blood cells, which depend on glucose for energy, are particularly affected. Over time, if alcohol abuse continues, fat will accumulate in the liver, leading to cirrhosis. Alcohol causes kidneys to excrete larger-than-normal amounts of water, resulting in an increased loss of minerals. In a poor nutritional state, the body is less able to fight off disease. In addition, excessive, long-term drinking can cause high blood pressure and can damage the heart muscle. It is associated with cancer of the throat and the esophagus and can damage the reproductive system. The risks to the drinker are obvious. When a pregnant or lactating woman drinks, however, she puts the fetus or the nursing infant at risk as well. Alcohol can lower birth weight and cause fetal alcohol syndrome or fetal alcohol effect, with related developmental disorders. Unfortunately, many teenagers ignore the dangers of alcohol and use it in an effort to appear adult. In addition to the damage to their own health and the accidents and the random acts of violence caused by their drinking, their behavior inspires younger children to emulate them. The health professional is in a good position to spread the message that alcohol is a substance and can cause severe economic and family problems, as well as addiction, disease, and death. **Marijuana** Marijuana use continues to increase among teenagers. Marijuana increases appetite, especially for sweets. One marijuana cigarette is as harmful as four or five tobacco cigarettes because the marijuana smoke is held in the lungs for a longer period of time. As marijuana is smoked, the lungs absorb the fat-soluble active ingredient, delta-9-tetrahydrocannabinol (THC), and store it in the fat (Indiana Prevention Resource Center, 2003). Experts believe that the use of marijuana can lead to the use of other drugs such as cocaine. Common street names for marijuana include grass, weed, pot, and dope. **Cocaine** Cocaine is highly addictive and extremely harmful. It causes restlessness, heightened self-confidence, euphoria, irritability, insomnia, depression, confusion, hallucinations, loss of appetite, and a tendency to withdraw from normal activities. Cocaine can cause cardiac irregularities, heart attacks, and cardiac arrests resulting in death. Weight loss is very common, mostly because it decreases appetite; addicts would give up food for the drug. The smokable form of cocaine is crack, which is more addictive than any other drug. It is estimated that half of all crimes against property committed in major cities are related to the use of crack cocaine and the addict's need for money to buy the drug. **Tobacco** Cigarette smoking is addictive. Cigarette smoking by teenagers is very prevalent. Teenagers smoke to "be cool," to look older, because they think it will help them lose weight, or because of peer pressure. Smoking can influence appetite, nutrition status, and weight. Smokers need the DRI for vitamin C plus 35 mg because smoking alters the metabolism. Low intakes of vitamin C, vitamin A, beta-carotene, folate, and fiber are common in smokers. Smoking increases the risk of lung cancer and heart disease. **Other Addictive Drugs** Methamphetamine is the most potent form of amphetamines. Amphetamines cause heart, breathing, and blood pressure rates to increase. The mouth is usually dry, and swallowing is difficult. Urination is also difficult. Appetite is depressed. The users' pupils are dilated, and reflexes speed up. As the drug wears off, feelings of fatigue or depression are experienced. Street names include crank, speed, crystal, meth, zip, and ice. Inhalants are chemicals whose fumes are inhaled into the body and produce mind-altering effects. Some inhalants are gasoline, lighter fluid, tool-cleaning solvents, model airplane glue, typewriter correction fluid, and permanent ink in felt-tip pens. Inhalants are both physically and psychologically addictive. Individuals who inhale may risk depression and apathy, nosebleeds, headaches, eye pain, chronic fatigue, heart failure, loss of muscle control, and death. **Nutrition for the Athlete** Good nutrition during the period of life when one is involved in athletics can prevent unnecessary wear and tear on the body as well as maintain the athlete in top physical form. The specific nutritional needs of the athlete are not numerous, but they are important. The athlete needs additional water, calories, thiamine, riboflavin, niacin, sodium, potassium, iron, and protein. The body uses water to rid itself of excess heat through perspiration. This lost water must be regularly replaced during the activity to prevent dehydration. Plain water is the recommended liquid because it rehydrates the body more quickly than sweetened liquids or the drinks that contain electrolytes. The "electrolyte" drinks are useful to replenish fluids after an athletic event but not during one. Salt tablets are not recommended because despite the loss of salt and potassium through perspiration, the loss is not equal to the amount contained in the tablets. If there is an insufficient water intake, these salt tablets can increase the risk of dehydration. The increase in calories depends on the activity and the length of time it is performed. The requirement could be double the normal, up to 6,000 calories per day. Because carbohydrates, not protein, are used for energy, the normal diet proportions of 50% to 55% carbohydrate, 30% fat, and 10% to 15% protein are advised. There is an increased need for B vitamins because they are necessary for energy metabolism. They are provided in the breads, cereals, fruits, and vegetables needed to bring the calorie count to the total required. Some extra protein is used during training, when muscle mass and blood volume are increasing. This amount is included in the DRI for age and is provided in the normal diet. Protein needs are not increased by physical activity. In fact, excess protein can cause increased urine production, which can lead to dehydration. The minerals sodium and potassium are needed in larger amounts because of loss through perspiration. This amount of sodium can usually be replaced just by salting food to taste, and orange juice or bananas can provide the extra potassium. A sufficient supply of iron is important to the athlete, particularly to the female athlete. Iron-rich foods eaten with vitamin C--rich foods should provide sufficient iron. The onset of menstruation can be delayed by the heavy physical activity of the young female athlete, and amenorrhea may occur in those already menstruating. When weight is a concern of the athlete, such as with wrestlers, care should be taken that the individual does not become dehydrated by refusing liquids in an effort to "make weight" for the class. When weight must be added, the athlete will need an additional 2,500 calories to develop 1 pound of muscle mass. The additional foods eaten to reach this amount of calories should contain the normal proportion of nutrients. A high-fat diet should be avoided because it increases the potential for heart disease. Athletes should reduce calories when training ends. In general, the athlete should select foods using MyPyramid. The pregame meal should be eaten 3 hours before the event and should consist primarily of carbohydrates and small amounts of protein and fat. Concentrated sugar foods are not advisable because they may cause extra water to collect in the intestines, creating gas and possibly diarrhea. Glycogen loading (carboloading) is sometimes used for long activities. To increase muscle stores of glycogen, the athlete begins 6 days before the events. For 3 days, the athlete eats a diet consisting of only 10% carbohydrate and mostly protein and fat as she or he performs heavy exercise. This depletes the current store of glycogen. The next 3 days, the diet is 70% carbohydrate, and the exercise is very light so that the muscles become loaded with glycogen. This practice may cause an abnormal heartbeat and some weight gain. Currently, it is recommended that the athlete exercise heavily and eat carbohydrates as desired. Then, during the week before the competition, exercise should be reduced. On the day before competition, the athlete should eat a high-carbohydrate diet and rest. After the event, the athlete may prefer to drink fruit juices until relaxed and then satisfy the appetite with sandwiches or a full meal. Many athletes will use "power drinks" or "energy drinks," which are not any better than soda and contain mostly sugar and empty calories. There are no magic potions or diet supplements that will increase an athlete's prowess, as may be touted by health food faddists. Steroid drugs should not be used to build muscles (Figure 13-6). They can affect the fat content of the blood, damage the liver, change the reproductive system, and even alter facial appearance. Good diet, good health habits, and practice combined with innate talent remain the essentials for athletic success. **CONSIDERATIONS FOR THE HEALTH CARE PROFESSIONAL** The health care professional who works with young children may encounter poor appetites and eating habits in her or his clients. Compounding this problem will be the anxiety of the clients' parents. They will understandably be concerned about their children's appetites and physical conditions. The health care professional can be most helpful to all concerned by exhibiting patience and understanding and by listening to parents and client. The problems of adolescent clients, perhaps particularly those with disordered eating, can be especially challenging. For example, telling an anorexic client to eat could be counterproductive. Health care professionals working with such clients should consult with the client's psychological counselor. Parents of clients with disordered eating must be included in both nutritional and family counseling. **DIET DURING YOUNG AND MIDDLE ADULTHOOD** Adulthood can be broadly divided into three periods: young, middle, and late adulthood. The first two periods will be discussed in this chapter. Late adulthood is discussed in Chapter 15. Young adulthood is a time of excitement and exploration. The age range runs from about 18 to 40 years of age. Individuals are alive with plans, desires, and energy as they begin searching for and finding their places in the mainstream of adult life. They appear to have boundless energy for both social and professional activities. They are often interested in exercise for its own sake and may participate in athletic events as well. The middle period ranges from about 40 to 65 years of age. This is a time when the physical activities of young adulthood typically begin to decrease, resulting in lowered caloric requirement for most individuals. Table 14-1 can help individuals estimate energy (calorie) requirements. During these years, people seldom have young children to supervise, and the strenuous physical labor of some occupations may be delegated to younger people. Middle-aged people may tire more easily than they did when they were younger. Therefore, they may not get as much exercise as they did in earlier years. Because appetite and food intake may not decrease, there is a common tendency toward weight gain during this period. During young to middle adulthood, the beginnings of osteoporosis may also be evident. A diet rich in calcium, vitamin D, and fluoride is thought to help prevent osteoporosis. The onset of rheumatoid arthritis (RA) usually occurs between the ages of 30 to 50 and will affect approximately 1% of the population (2.1 million), women outnumbering men three to one. RA affects the wrists, joints of the fingers other than those closest to the fingernail, hips, knees, ankles, elbows, shoulders, and necks. Although researchers have determined that diet changes have no effect on rheumatoid arthritis, it is still important to maintain a healthy diet that includes adequate calcium and protein. A multiple vitamin containing vitamin D and a calcium supplement should be taken daily. Omega-3 fatty acids have been helpful in reducing inflammation, but a physician should be consulted before taking this supplement. **NUTRITIONAL REQUIREMENTS** Growth is usually complete by the age of 25. Consequently, except during pregnancy and lactation, the essential nutrients are needed only to maintain and repair body tissue and to produce energy. During these years, the nutrient requirements of healthy adults change very little. The iron requirement for women throughout the childbearing years remains higher than that for men. Extra iron is needed to replace blood loss during menstruation and to help build both the infant's and the extra maternal blood needed during pregnancy. After menopause, this requirement for women matches that of men. Protein needs for healthy adults are thought to be 0.8 gram per kilogram of body weight. To determine the specific amount, one must divide the weight in pounds by 2.2 to obtain the weight in kilograms and then multiply the weight in kilograms by 0.8. The current requirement for calcium for adults from 19 to 50 is 1,000 mg, and for vitamin D, 5 microgram. Both calcium and vitamin D are essential for strong bones, and both are found in milk. Bone loss begins slowly, at about the age of 35 to 40, and can lead to osteoporosis later. Therefore, it is wise for young people, especially women, who are more prone to osteoporosis than men, to consume foods that provide more than the requirements for these two nutrients. Three glasses of milk a day nearly fulfill the requirement for each of these nutrients. Increasing this amount could prevent osteoporosis. Fat-free milk or foods made from fat-free milk should be consumed to limit the amount of fat in the diet. **CALORIE REQUIREMENTS** Calorie requirements begin to diminish after the age of 25, as basal metabolism rates decrease (Table 14-2). After 25 years, a person will gain weight if the total calories are not reduced according to actual need, which will be determined by activity, BMI (REE), and amount of lean muscle mass. Those who are more active will require more calories than those who are less active. **SPECIAL CONSIDERATIONS RELATED TO NUTRITION CONCERNS** It is especially important to maintain good eating habits during young and middle adulthood. Women, who may be concerned about weight, cost of food, or time, can easily develop nutrient deficiencies. For example, a woman who settles for a piece of pie at lunchtime while her husband eats a hamburger and salad is being very foolish. If she continues to eat like this, she will jeopardize her health. A hamburger can have 250 to 400 calories. The salad will contain less than 50 calories without dressing, and the dressing could be limited to 1 tablespoon, or approximately 100 calories, for a total intake of about 400 to 550 calories. Pies average 100 calories per 1-inch slice. Most slices are about 3 1⁄2 inches. A scoop of ice cream on the pie would bring the total to at least another 100 calories. Although the calorie intakes of the husband and wife would be comparable, the nutrient intakes would differ. The wife's would be inadequate. If the woman is of childbearing age and plans to have children, she or her children could suffer from such habits. In general, people today are concerned about nutrition and want to limit fats, cholesterol, sugar, salt, and calories and increase fiber. Many know the sources of these items; others do not. Unfortunately, both groups tend to select their food because of convenience and flavor rather than nutritional content. It is easier to drive through a fast-food restaurant or heat a prepared frozen dinner in the microwave and complete the meal with ice cream than it is to shop for individual food items, cook them, and wash up after the meal. Consequently, many people ingest more fats, sugar, salt, and high-calorie foods and less fiber and other nutrients than they should. **WEIGHT CONTROL** Weight control is one of the top concerns of all adults. Whether for reasons of vanity, health, or both, most people are interested in controlling their weight. It is advisable because overweight can introduce health problems. Cases of diabetes mellitus, metabolic syndrome, and hypertension are more numerous among the overweight than among those of normal weight. Overweight individuals are poor risks for surgery, and their lives are generally shorter than are those of people who are not overweight. They are prone to social and emotional problems because overweight and obesity can reduce self-esteem. The causes of overweight are not always known, but the most common cause appears to be energy imbalance. In other words, if one is overweight, chances are that more calories have been taken in than were needed for energy. An intake of 3,500 calories more than the body needs for maintenance and activities will result in a weight gain of 1 pound. An individual who overeats by only 200 calories a day can gain 20 pounds in 1 year. Obviously, when nutrient requirements remain static but calorie requirements decrease, people must select their foods carefully to fulfill their nutrient requirements (Table 14-3). Genetics and, rarely, a hypothyroid condition, can also contribute to overweight. Individuals who are overweight simply because of energy imbalance can solve the problem by eating less and increasing physical exercise. Exercise will increase the number of calories burned. However, unless the exercise is sufficient to burn more calories than the ingested food contains, exercise alone will not solve the problem. By far the most effective method of weight loss is increased exercise combined with reduced calories. This will help tone the muscles as excess fat is lost. Exercise may also increase lean muscle mass in such a way that weight loss will not be necessarily significant; in this case, a decrease in clothing size may be a better indicator of fat loss. When weight reduction is to be undertaken, the client should confirm with his or her physician that he or she is in good health. Then, with the help of a registered dietitian, a healthy eating plan should be developed that will fit the dieter's lifestyle. A healthy eating plan is easiest to follow when it is based on Food Pyramid. This plan will aid the dieter in obtaining needed nutrients, will help change previously unsatisfactory eating habits, and will allow him or her to adapt, and thus enjoy, home, party, or restaurant meals. For additional information about weight loss diets. **CONSIDERATIONS FOR THE HEALTH CARE PROFESSIONAL** The young and middle years of life are busy. Most people feel they have too many things to do and too little time to accomplish them. Most have families, jobs, and social obligations and, thus, more responsibilities. **DIET DURING LATE ADULTHOOD** The rate of aging varies. Each person is affected by heredity, emotional and physical stress, and nutrition. Research continues to reveal more about the causes of aging and the role of nutrition in the aging process. **THE EFFECTS OF AGING** As people age, physiological, psychosocial, and economic changes occur that affect nutrition. **Physiological Changes** The body's functions slow with age, and the ability of the body to replace worn cells is reduced. The metabolic rate slows; bones become less dense; lean muscle mass is reduced; eyes do not focus on nearby objects as they once did, and some grow cloudy from cataracts; poor dentition is common; the heart and kidneys become less efficient; and hearing, taste, and smell are less acute. If poor nutrition has been chronic, the immune system may be compromised. Osteoarthritis and its debilitating effects are of great concern to the elderly. Arthritis can limit the ability to perform activities of daily living (ADLs). The role that diet plays in arthritis has been of increasing interest to researchers. Excessive weight, certain vitamin deficiencies, and the type of diet being followed may influence some types of arthritis. Eating a healthy, well-balanced diet that includes the "5 a day" fruits and vegetables, along with grain products, and sugar and salt in moderation, may be beneficial for arthriti