PSIO335-Module 1- Lifespan Nutrition All.pdf

PSIO335 - Module 1- Lifespan Nutrition Lifespan Nutrition: introduction Over the lifespan of a human, nutritional needs change. There are many interacting factors that affect the amount and types of nutrients and energy that is required at certain stages. These include per...

PSIO335 - Module 1- Lifespan Nutrition Lifespan Nutrition: introduction Over the lifespan of a human, nutritional needs change. There are many interacting factors that affect the amount and types of nutrients and energy that is required at certain stages. These include periods of increased growth, changes in metabolism, hormonal changes or the increased energy and nutrient and energy demands during pregnancy. It is vital for a health practitioner to know and understand this variety to offer the best care for clients at any stage of life. 1. Pregnancy and infant nutrition Learning goals Understand the different nutritional requirements on the mother between pre- pregnancy, pregnancy and lactation. Identify public health measures that aim to prevent/ minimize the chance of birth defects Identify the factors that influence the foetal nutritional status. Know the energy costs associated with the different stages of pregnancy. Know the healthy birth weight range and the risks associated with low birth weights. Know the associated risks to the mother and infant when the mother is obese. Know the requirements of energy, protein, folate, calcium, iron, zinc, iodine and vitamin A, D and K during pregnancy, and know clinical conditions associated with a deficiency or excess. Understand the factors that influence the composition of breast milk. Understand the total energy cost of lactation. List the benefits of breast feeding over infant formulas. Define “Failure to Thrive” Describe use the effectiveness of CDC growth charts Understand the changes in the mother and baby microbiome during pregnancy and after birth Essential Readings: Essentials of Human Nutrition (Mann and Truswell) Chapter 32 Pre-pregnancy, pregnancy and lactation (pg 523-536) Essentials of Human Nutrition (Mann and Truswell) Chapter 33 Infant and Toddler Feeding (pg 537-551) Suggested additional reading: FSANZ Pregnancy and Healthy Eating, available at http://www.foodstandards.gov.au/consumer/generalissues/pregnancy/Pages/default.as px PSIO335. Lifespan Nutrition notes pg. 1 1.1. The Mother Nutrition in pre-pregnancy The health of an infant is closely tied to the health of the mother – even before conception. Although some nutrition intervention immediately prior to conception can improve the health outcomes of the foetus, the lifelong nutritional and health status of the mother will have a much more significant impact. Being of a healthy body weight, with optimal nutrition intake and stores prior to becoming pregnant are associated with better pregnancy outcomes. While many mothers can alter their eating plan when trying to become pregnant to increase the likelihood of a healthy baby, many pregnancies are unplanned. Being in good health and eating a balanced diet can help protect the foetus in these unexpected pregnancies. Maternal weight status Subjects who are underweight or have reduced energy stores may experience complications conceiving or during pregnancy. Amenorrhoea (delayed or ceased menstruation) is commonly reported in women who experience rapid or excessive weight loss or in cases of Anorexia Nervosa. Those with a body fat percentage below 22% are less likely to ovulate (a normal, healthy female averages 28% body fat). Delayed age of menstruation onset has been documented in females undergoing significant athletic training, or those who displayed disordered eating. On the other hand, earlier onset of menstruation is often observed in females with an excessive nutrient consumption. Women who are obese (BMI > 30kg/m2) are more likely to have difficulties conceiving than those within the healthy range, however a reduction of 5-10% of body weight can assist in overcoming this issue. Nutritional recommendations for pre-pregnancy Women who wish to conceive are recommended to aim for the RDI for all nutrients and follow the Australian Dietary Guidelines to promote good health. On top of this, it is recommended that folate intake is increased, usually in the form of a folic acid supplement. This recommendation is made to reduce the risk of neural tube defects (NTDs) in infants, but cannot always be implemented, even by highly health conscious individuals, as many pregnancies are unplanned. NTDs are malformations where the neural tube does not close properly during early foetal development, including conditions such as Spina Bifida, Anencephaly and Encephalocele. There are also genetic factors that affect the onset of these conditions, but appropriate folic acid supplementation has been shown to prevent the defects in most pregnancies. Focus 1.1: Folate (see separate slides) 1.2 The Foetus Pregnancy is a time of rapid foetal development. Adequate nutrition is required to enable the foetus to grow and develop, and will influence the health of the infant into childhood and adulthood. PSIO335. Lifespan Nutrition notes pg. 2 However, the rate of growth is not steady throughout the entire pregnancy, and as such the nutritional needs vary as the pregnancy progresses. Stages of foetal growth In the first eight weeks of pregnancy, energy requirements are not increased above the regular requirements of the mother. In this stage, optimal nutrient consumption is essential though, as in this period growth and development of embryonic tissue is underway and new tissues are being laid down. 1. Blastogenesis – The first two weeks after conception, this stage is where the fertilized ovum divides to form the blastocyte that implants into the uterine wall. 2. Embryonic – This stage makes up the next six weeks of development where principle tissues are laid down to form key body tissue and organs. 3. Foetal – This stage refers to the rest of the pregnancy term. Energy requirements Contrary to the common saying that a pregnant woman should be ‘eating for two’, energy requirements do not increase hugely during pregnancy – especially not in the first trimester. The energy ‘cost’ of pregnancy is calculated considering all growth and changes that are required including the energy required for the foetus, placenta and other maternal tissues, and the extra energy expenditure required for carrying a greater body mass. This has been calculated to be 325MJ over the whole pregnancy using doubly labeled water techniques (for an average woman who gains 12kg weight during the pregnancy). As there is very little increase in tissue mass in the first trimester, no additional energy intake is allocated for this time. Distributing the 325MJ between the last two trimesters according to growth, this figure has been used to recommend an increase in intake of 1.4MJ and 1.9MJ per day in the second and third trimesters respectively in Australia. Note: remember that 1MJ = 1000kJ Expected weight gain throughout the three trimesters is as follows: Trimester 1 – 11% of total Trimester 2 – 47% of total Trimester 3 – 42% of total It is important for the mother to gain an appropriate amount of weight for adequate foetal growth and thus birth weight, however, excessive weight gain during pregnancy increases the risk of having a large baby (>4200g), and is associated with a greater likelihood of caesarean delivery and post partum obesity. The normal weight gain for most women is approximately 11-15kg. QUESTION Why do you think there a greater energy intake recommended in the third trimester, when the largest percentage of growth occurs in the second trimester? PSIO335. Lifespan Nutrition notes pg. 3 Maternal and baby weight Mothers within the obese weight range have a higher risk of experiencing health difficulties associated to their pregnancy such as gestational diabetes, miscarriage, pre-eclampsia, thromboembolism and maternal death. Weight reduction is not recommended during the pregnancy, however there are some suggestions that women who start their pregnancy at a high body weight should be encouraged to gain less during the term. However, the evidence behind this is limited. Appropriate weight reduction measures should be encouraged after the birth. The impacts on the baby may include: Higher risk of foetal death Stillbirth Congenital abnormality Shoulder dystocia Macrosomia Subsequent obesity of infant Low birth weight (LBW) is associated with increased rates of infant mortality and is linked with long- term morbidity. Infants born under 2500g are considered to be in this category. Growth deficits and delayed cognitive development are more common in LBW children, while as adults these clients are more prone to diabetes and heart disease. There are many factors that can contribute towards a LBW, including low maternal body weight, and adolescent pregnancies (nutritional requirements are higher in these cases as the mother is also still developing and growing). Some lifestyle factors are also shown to be contributive, including smoking or a high caffeine intake during pregnancy. LBW babies are at a higher risk of: Hypertension Type 2 diabetes Coronary Heart Disease Birth weight classifications Low birth weight Normal birth weight High birth weight ≤2499g 2500-4200g ≥4201g Foetal nutrient supply The relationship between maternal oral intake and foetal nutrition is indirect, as there are many factors that can affect the supply. These include: Increased maternal absorption of some nutrients (e.g. iron). Increased bone turnover (to meet calcium needs). Increase in circulating blood volume resulting in reduced concentration of red blood cells. Decreased plasma levels of water soluble vitamins, and increased fat soluble vitamins. Reduced haemoglobin concentration PSIO335. Lifespan Nutrition notes pg. 4 The regulation of the nutrient supply protects the foetus from poor maternal nutrition by ‘buffering’ the nutrient availability depending on intake and nutrient stores. The placenta is the organ responsible for nutrient exchange from the mother to the foetus. The placenta keeps the foetal blood supply separate from the mother’s, allowing oxygen and nutrients to flow to the baby, while waste products are transferred back to the mother for elimination. The placenta uses varying methods of nutrient transfer mechanisms, including: diffusion facilitated diffusion active transport Nutritional recommendations in pregnancy While good general nutrition is required in pregnancy, there are some nutrients of specific importance to a mother and her developing foetus. Protein Protein requirements are increased in pregnancy to allow for the synthesis of the new foetal, placental and maternal tissues. The RDI for pregnant women (19 years and older) was determined at 1.0g/kg body weight per day; an increase from the 0.75g/kg body weight per day that is recommended for non-pregnant women. This recommendation should only be implemented during the second and third trimesters, as growth during the first trimester is minimal. Folate See focus 1.1 Calcium Calcium is vital for foetal bone mineralization and also the maintenance of the mother’s bone structures. The majority of foetal calcium is laid down in the final 10 weeks of gestation. While the requirement for calcium is increased in pregnancy, an increased intake is not deemed necessary. Alterations in the maternal metabolism and an increase in the mother’s efficiency in calcium absorption upon consumption are adequate to provide additional calcium as required. In light of this, the maternal calcium intake is recommended at 1000mg/day as this is the RDI for women of childbearing age in the general population. Iron Maternal iron deficiency is linked with premature delivery, LBW or even perinatal death. Iron needs in trimester one are not significantly increased due to the cessation of menstruation, but recommendations still remain high during all three trimesters as it is thought that stores can be built and maintained during the entire term. In Australia the RDI for iron in pregnancy is 27mg/day, significantly higher than the 18mg/day recommended for non-pregnant females of childbearing age. This value was set based on the average biological availability of the iron sources in a mixed (meat and plant based) diet. Vegetarian mothers should increase iron intake further to allow for the lower absorptive capacity of a plant based diet. PSIO335. Lifespan Nutrition notes pg. 5 Zinc Zinc is required for foetal growth and development and to promote full term delivery. A maternal deficiency is linked with growth retardation, abnormalities in the foetus and birth complications in the mother. Additional zinc is required during pregnancy, but supplementation is not recommended. Food sources should be consumed, ensuring that food safety is considered. Iodine Iodine deficiency during pregnancy remains a significant public health problem. A severe lack of iodine during foetal development can result in cretinism with stunted physical and mental development. These issues can usually be easily avoided by the use of iodized salt, or a maternal injection during pregnancy. Vitamin A Vitamin A intake during pregnancy must be considered to ensure it is not inadequate, or excessive. A deficiency can lead to increased risk of blindness, depressed immune function, other illnesses and death from measles and other infections. An excessive intake of vitamin A (>3000μg per day) can lead to central nervous system and heart defects. For this reason it is recommended to consume foods rich in vitamin A, but avoid very rich sources such as liver, liver products, supplements, fortified foods and fish oil supplements high in retinol. Vitamin D An insufficient intake of vitamin D during pregnancy is linked with lower maternal weight gain and disturbance in skeletal/muscular activity in infants. In extreme cases, reduced bone mineralization, rickets and fractures can occur. Vitamin C As the foetus appears to concentrate vitamin C at the expense of the mother, it is recommended that intake be increased during pregnancy. This can be done by simply choosing higher vitamin C food sources. The RDI of various nutrients required in pregnancy and lactation. Women 19-30 years Pregnant Women Lactating Women Protein 46 g (0.75 g/kg) 60 g (1.00 g/kg) 67 g (1.1 g/kg) Folate 400 µg 600 µg 500 µg Calcium 1000 mg 1000 mg 1000 mg Iron 18 mg 27 mg 9 mg Zinc 8 mg 11 mg 12 mg Iodine 150 µg 220 µg 270 µg Vitamin A 700 µg 800 µg 1100 µg Vitamin D 5.0 µg (AI) 5.0 µg (AI) 5.0 µg (AI) Vitamin C 45 mg 60 mg 85 mg PSIO335. Lifespan Nutrition notes pg. 6 READ Read through the following article Brown, B., & Wright, C. (2020). Safety and efficacy of supplements in pregnancy. Nutrition reviews, 78(10), 813-826. https://academic.oup.com/nutritionreviews/article/78/10/813/5700577 Identify the issues and difficulties for gathering scientific evidence on pregnancy vitamins and minerals supplements. Critically review the information provided on at least 3 supplements and form a justified opinion on their efficacy. Share your views on the Moodle general discussion forum, we’ll also discuss your views in the tutorial. Lifestyle concerns There are many lifestyle factors that can have a negative effect on pregnancy outcomes. Over the years, efforts have been made to promote Alcohol Heavy drinkers have an increased risk of foetal alcohol syndrome, although no level of alcohol intake has been proven to be safe during pregnancy. Foetal alcohol syndrome is a condition characterized by underdevelopment of the mid-face, a lower birth weight and mental retardation. The most crucial time of development where the foetus is most susceptible is during embyogenesis. This period is during the first few weeks of trimester one, and many women can be unaware they are pregnant. For this reason, it is vital that women who are trying to become pregnant should limit or cease alcohol intake. Australian recommendations suggest that no alcohol should be consumed while pregnant or breastfeeding. Smoking Smoking during pregnancy is strongly linked with a low birth weight, as this behaviour can cause retardation of foetal growth. There is also a much greater risk of spontaneous abortion, preterm delivery and SIDs. Exercise Although moderate exercise is a healthy behaviour to undertake during pregnancy, high impact activities can cause a low birth weight and other complications. Pregnant women who are healthy and have no complications should be encouraged to participate in moderate intensity cardio and strength conditioning exercise. The benefits of such training include a reduced risk of gestational diabetes, a shorter labour and lower likelihood of surgical intervention. The regular benefits of exercise such as weight control and increased fitness are also beneficial. Caffeine Maternal caffeine intake is associated with an increased risk of spontaneous abortion and low birth weight. As caffeine freely crosses the placenta, it is recommended that intake be limited. An upper intake of 200mg per day is recommended (approximately two cups of instant coffee or a single espresso shot), but many women choose to abstain from caffeine. PSIO335. Lifespan Nutrition notes pg. 7 Oily fish While it is still considered beneficial to consume fish during pregnancy, the quantity and species that is consumed should be monitored. Oily fish can store contaminants, particularly mercury, which can lead to toxicity when consumed at higher levels. FSANZ recommends limiting intake to 100g per fortnight of flake, merlin or swordfish OR 100g per week of perch or catfish. If these are consumed, no other fish should be consumed in the timeframe. Food safety Avoiding food borne illness is a particular concern during pregnancy. Both salmonella and Listeria Monocytogenes infection poses a greater threat during pregnancy than at other times. Listeriosis can result in a mild chill, or in more severe cases a preterm birth or stillbirth. Precautions that can limit the risk of exposure include: Avoiding soft cheese (e.g. camembert, feta) and blue cheese types Avoiding pates and cold meats (e.g. sliced ham) Avoiding pre-prepared salads and sandwiches Avoiding raw eggs in any form Effects of pregnancy on nutritional intake While pregnancy alters the nutritional needs of the mother, it also in many cases alters the nutritional intake in many ways. The common onset on nausea and vomiting can limit the nutritional intake of the mother, and also change the types of foods that are consumed. Cravings and aversions are also common and can indicate an increase or decrease in specific foods or drinks. However it is thought that the onset of all these interferences may be the body’s natural protection of the developing foetus. Careful professional nutritional planning may be required in some circumstances to ensure that a mother highly affected by nausea or food aversions is still able to reach the required nutrient intakes for healthy growth and development of the foetus. READ The Australian Dietary Guidelines are inclusive of recommendations suitable for pregnant women. Read the following brochure provided by the Australian Government regarding recommendations for healthy eating during pregnancy. Nutrition in pregnancy. https://www.eatforhealth.gov.au/sites/default/files/files/the_guidelines/ n55h_healthy_eating_during_pregnancy.pdf Nutrition in Lactation In Australia, a large percentage of mothers commence breastfeeding, but few continue to exclusively feed with breast milk until six months. While ‘encourage, support and promote breastfeeding’ is included as a dietary guideline in Australia, there are many factors that influence the decision to commence or continue breast feeding. PSIO335. Lifespan Nutrition notes pg. 8 When there are no complications with suckling and the milk supply, the mother is able to provide adequate amounts of breast milk through a ‘positive feedback’ system. The suckling of the infant stimulates the pituitary gland to release prolactin, a hormone required for the synthesis of breast milk. The appropriate combination of proteins, fats and sugars are synthesized, and mixed with other nutrients from the mother’s circulating plasma. Another pituitary hormone, oxytocin, then triggers the release of the newly formed milk into the ducts that carry the milk to the nipples. Breastfeeding and milk supply: Positive feedback cycle Breast milk composition Breast milk is sufficient source of nutrition for the first six months of an infant’s life. The composition and volume of the milk changes as the baby’s needs change over the stages of lactation, and also PSIO335. Lifespan Nutrition notes pg. 9 during each day and each feed. The mother’s dietary intake and nutritional status also plays a role. The amount of milk produced varies significantly, but the average infant intake is 750-800ml daily. During the first week after birth, the milk that is produced is called colostrum. This is a low fat content milk, with higher carbohydrates, protein and antibodies for immune function, such as IgA, lactoferrin and leukocytes. The fat content of colostrum is 2.6g/100mL. Over the next seven days the milk transitions to mature milk. The antibody content decreases, but the fat content and the milk volume increase. The fat content of this mature milk is 4.2g/100mL. READ Read the following paper titled Human Milk Composition: Ballard, O., & Morrow, A. L. (2013). Human milk composition: nutrients and bioactive factors. Pediatric Clinics, 60(1), 49-74. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3586783/ This paper provides an in-depth explanation of the changes in breastmilk. Maternal nutrient requirements During pregnancy the mother’s body will store some additional nutrients and energy in preparation for lactation. Nutrient and energy requirements are high during lactation, as the mother’s intake (and existing stores) must now provide not only her needs, but the needs of a growing infant as well. The total energy cost of lactation is counted as the energy content of the milk produced, plus the energy required by the mother’s body to produce the milk. Women who are exclusively breast feeding may require an additional 2400kJ per day (assuming that some energy is provided by fat stores, therefore supporting post natal weight loss). It was previously thought that lactating women should increase their calcium intake to compensate for the increased loses in breast milk. It has since been realized that increasing intake does not prevent the mobilization of calcium in the bones, so an intake above the requirements of non-lactating women is not required. During lactation, it is recommended to avoid or limit alcohol and caffeine intake. Both of these substances flow freely between the blood and breast milk, meaning that the concentration in the milk is the same as the blood. The only way to reduce the amount of alcohol or caffeine in the blood is to wait the appropriate amount of time, and the same is true of breast milk. If choosing to drink either alcohol or caffeine while breastfeeding, preplanning is essential. The concentration of these substances is highest at 30-60 minutes, so infant feeding, or expressing of milk should be avoiding at this time. If consuming alcoholic drinks, the milk will still contain alcohol as long as the blood. Regular guidelines for the time required to breakdown a standard drink should be followed (i.e. one standard drink takes two hours to breakdown). Caffeine should be avoided for the first three to six months of breastfeeding as very young infants do not process caffeine efficiently. After this, it should be safe to consume up to two caffeinated drinks PSIO335. Lifespan Nutrition notes pg. 10 daily. However, some mothers may find that caffeine causes their infant to become unhappy or to sleep poorly. In these cases the amount consumed should be reduced or completely cut out. READ Go to the following website and look at the smartphone application available for breastfeeding mothers to gauge alcohol consumption. http://www.feedsafe.net Health outcomes with breastfeeding The benefits of breastfeeding are well documented, with both physical and psychological benefits identified. Breast milk provides the infant with the appropriate nutrition for the stage of growth, immune protection, and helps form an emotional bond between infant and mother. Breastfed infants also benefit in later life, displaying lower risk of: Gastroenteritis Respiratory conditions Obesity Type 1 and 2 diabetes Allergies and intolerances In addition to this, mothers who breastfeed are at lower risk of obesity and ovarian and breast cancer. Formula feeding Not all mothers are able or inclined to breastfeed. In these cases, there are a few options, including expressing breast milk, using a breast milk and formula combination or opting for a baby milk formula. These milk formulas mimic the composition of breast milk to promote the proper growth and development of the infant. In Australia there are stringent guidelines released by FSANZ to ensure that all formulas on the market meet the nutritional requirements of growing infants. This code divides infant formulas into three categories: Infant formula (satisfies by itself the nutritional needs of an infant under 4-6 months) Follow on formula (suitable as the main form of liquid nourishment for infants over 6 months) Formula for special dietary use (products designed to meet the needs of infants with specific dietary requirements). While evidence indicates more positive health outcomes with breastfeeding, these formulas provide an adequate nutrient intake for the healthy growth of the infant when used correctly. FSANZ and other health promoting bodies warn against the rise of ‘homemade’ infant formulas. The recipes available both online and in print are not regulated in any way, and can pose a health risk to PSIO335. Lifespan Nutrition notes pg. 11 infants who are fed using such recipes. In some cases unsafe ingredients are used, while others simply do not provide the appropriate nutrients for proper growth and development of the infant. READ The legislation surrounding the composition and promotion of infant formulas is available here: https://www.legislation.gov.au/Details/F2015L00409 2. Childhood and Adolescence Learning Goals Understand the specific dietary requirements of children and adolescents. Describe the main causes of morbidity in childhood and adolescence, and understand the dietary/therapeutic interventions required. Understand child/adolescent growth patterns and methods of assessing growth. Essential readings Essentials of Human Nutrition (Ed 4), Mann and Truswell, Chapter 33 Infant and Toddler Feeding (pg 537-551) Essentials of Human Nutrition (Ed 4), Mann and Truswell, Chapter 34 Childhood and Adolescent Nutrition (pg 554-570) NHMRC Infant Feeding Guidelines Summary, available at: https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n56_infant_fee ding_guidelines_summary_150916.pdf Infant Feeding The first year of life is a vital period, as the rate of growth and development is more rapid than at any other point in the lifecycle. An infant is likely to triple in weight between birth and its first birthday. To support this growth, the infant must be provided with adequate energy, and also nutrients. The energy and nutrients requirements are highest per kilogram of body weight during this period than any other life stage. Breast milk is specifically designed for the needs of healthy newborn babies and is considered the ideal Weaning from breast feeding PSIO335. Lifespan Nutrition notes pg. 12 While breast milk or a carefully designed formula schedule provides all the nutrients required for a newborn baby, over time the infant’s needs exceed that which is provided by these products. Prolonged breast feeding without supplementation of solid foods can lead to poor growth rate, wasting and iron deficiency. Foods should be introduced slowly, starting when the infant is between four and six months of age. Each infant is different and the optimal time will vary. It is recommended that foods be introduced one at a time, in small amounts, such as a teaspoon or two daily. Over time the amount can be increased. Breast feeding should continue as normal during this stage. Foods offered must be smooth in texture, such as cooked and mashed potato, infant cereals, soft mashed fruits or pureed meats. The frequency and size of solid meals can be gradually increased, and the infant introduced to a wider variety of foods. If a food is rejected, it should be offered multiple times of different occasions to allow the infant to become familiar with the item. The parents must ensure that proper hygiene is maintained at all times, as infants are more susceptible to food born illness than adults, and signs of allergy or intolerance should be monitored after introducing each new food. Poor Growth Poor growth, or commonly ‘failure to thrive’ is a term used to describe delayed weight gain in infants, compared to expected rates. As each child’s rate of weight and height gain is different, growth should be plotted over time on growth charts to track the progress of each child individually. Children whose weight gain begins to ‘drop off’ or trend downwards, or those children tracking under the third percentile may be flagged as possibly displaying poor growth. These children should be monitored carefully to ensure that any issues are determined. It is possible that a child tracking in the lower percentiles of growth is simply a healthy, but small infant. Nutrition is the main indicator of growth rate, but there are varying causes for a limited nutritional intake. These can include: Breast feeding difficulties resulting in not enough milk for baby Loss of energy/nutrients through excessive vomiting or chronic diarrhoea Inaccurate measurement for diluting formula Delayed introduction of solids, or inappropriate foods offered to baby Absorptive issues, such as coeliac disease or other intolerances Chronic conditions, such as Diabetes, Cystic Fibrosis or Congenital Heart Disease. Family difficulties such as poverty, mood disorders in parents, substance abuse by parents Child neglect or abuse Poor education or limited understanding of infant feeding by parent When identified, poor growth should be carefully monitored by a health professional, while investigations are taken out to seek clarification on the cause of inadequate nutrition. It is possible that no specific issues will be found, and that the child’s lower growth rate will resolve in time. In all cases, monitoring should continue. If left unchecked, consequences of poor growth can include a PSIO335. Lifespan Nutrition notes pg. 13 continued growth deficit, lasting effects on appetite/feeding habits, low maternal self-esteem, and child developmental delays. Infant growth assessment Infant growth can be measured in a variety of ways, but the option most common method is to use growth charts such as those developed by the WHO or the CDC. In infants (under two years) the WHO charts are recommended. These charts are developed using data from carefully designed studies that assess the growth of children in six countries who live in environments considered to be ‘optimal’ for growth. These charts are used over the first two years of the infant’s life to plot the weight and length changes in order to track growth progress. The charts below are commonly used, but other charts are available that also monitor head circumference. Separate charts are used for boys and girls. WHO Growth Charts 0-24 months PSIO335. Lifespan Nutrition notes pg. 14 PSIO335. Lifespan Nutrition notes pg. 15 Further investigations must also be undertaken including information on the infant’s feeding history (including whether breast or formula fed, frequency and volume consumed, whether solids are consumed, any difficulties with meals or feeding). Other investigations may include parent perception towards feeding, socioeconomic status, infant’s willingness to accept solids, relevant medical investigations, and physical investigations (i.e. assessing the presence of muscle and subcutaneous fat stores, checking for signs of neglect or mistreatment). PSIO335. Lifespan Nutrition notes pg. 16 Interventions If an infant is identified as presenting with poor growth, interventions will be implemented as appropriate by a paediatrician, dietitian or other physician. Treatment is highly tailored to the individual infant and family. In lower risk cases, advice and recommendations on increasing nutrition can be provided to parents for implementation (continued monitoring is still vital) If a chronic condition is identified (such as Coeliac Disease) advice on managing the condition is key. In some cases hospital admission may be required to replace fluids in dehydration (e.g. with chronic diarrhoea) or provide care for illnesses. In cases where parent neglect or abuse is discovered, Child Protection Agencies must be notified. While it is highly preferable that nutritional needs are met through foods and breast milk, in some specific cases, it may be required that supplements formulas or nutrients supplements are added to the infant’s diet. Examples may include Aptamil Toddler formula, Karicare Specialist formulas, or Similac formulas. Each of these should only be used under the guidance of a health professional, as formula supplementation should not be considered as the first option for meeting infant nutritional needs. Childhood nutrition Childhood is a vital time for growth and development, but also for setting up the child with healthy lifestyle habits that they will likely maintain into their adult years. While in the past there has been specific dietary guidelines in Australia for children and adolescence, these have been replaced with the Eat For Health Australian Dietary Guidelines Key nutrients Iron Iron requirements are increased in stages of growth, making it an essential nutrient in childhood. As girls move into puberty (14-18 year age group), the RDI for this nutrient increases to 15mg per day. This is to allow for menstrual losses after menarche. Iron recommendations are included in the table below. Age group RDI 1-3 years 9mg/day 4-8 years 10mg/day 9-13 years 8mg/day 14-18 years 11mg/day (boys) 15mg/day (girls) PSIO335. Lifespan Nutrition notes pg. 17 It is common for adolescent females to be iron deficient or at risk of iron deficiency anaemia, as they may not be reaching their increased requirements. A contributing factor can be the trend for adolescent females to eliminate meat from their diet. This can be either in response to awareness of animal cruelty, for peer acceptance or in an effort to reduce food intake for weight loss. A switch to a vegetarian or vegan diet can be a warning sign for disordered eating. In many cases, due to poor food knowledge, meat and animal products can be removed from the diet without appropriate replacement with non-meat alternatives. This can cause deficiencies in iron intake as well as zinc, vitamin B12, protein and other nutrients. Vitamin D Although not common, the prevalence of vitamin D deficiencies is increasing in children, especially in populations with darker skin, or where the skin is kept covered. As vitamin D is a fat soluble vitamin, malabsorption disorders can also inhibit uptake of vitamin D by the body. Low vitamin D intakes in children has been linked to increased susceptibility to infection and Type 1 diabetes. In order to prevent these issues along with rickets and the lower bone density that can be observed in vitamin D deficient children, it is best to consume foods naturally high in vitamin D such as eggs and fatty fish, as well as those fortified, including margarine and some milks and yoghurts. Some exposure to sunlight is also important. Five to 15 minutes of exposure of the face and arms four or more times per week is adequate. Growth During the years of childhood, growth patterns and nutritional requirements alter significantly. There are also large differences between genders and individual children in the energy and nutrients requirements. There are two significant stages of rapid growth – once during the first year of life, and the second with the onset of puberty. Each child will also undergo phases of increased or reduced growth rates as they develop, which can cause an increase in requirements. Assessing growth Due to the variable healthy rates of growth that can be seen in children, a single measure of weight or height is not adequate to monitor whether a child’s growth is optimal or not. Because of this, it is recommended that growth charts be used. These charts allow health professionals to track the child’s growth over time and monitor how they are tracking. These charts, as with the infant growth charts, were developed based on the results of large studies of children. However, the CDC charts are based on data from the USA alone. These charts are still considered appropriate for use in Australia. Using growth charts In order to use growth charts effectively, multiple measures must be taken over time and plotted accurately. The percentile bands or curves represent the reference population for comparison to the subject. The 50 percentile curve represents the mean – indicating that 50% of healthy children are above this measurement and 50% are below. At the top and bottom of the chart, the 95th percentile PSIO335. Lifespan Nutrition notes pg. 18 indicates that only 5% of healthy children are above this curve, and the 5th percentile indicates that 5% of children are below this curve. This means that 90% of health children should be tracking between these two curves. Using this same logic, it is evident that 50% of healthy children will be between the 25th and 75th percentile curves. However, as previously discussed, each child has an individual healthy growth rate and it is more important to track the child’s growth over time than compare to other children. It is recommended that height and weight both be measured and documented on the growth charts, but only weight will be demonstrated in the example below. In addition to the weight for age and stature for age charts, there is also a BMI for age chart available for use. BMI calculations and the associated interpretation as used in adults is known to not be appropriate for use with children. The charts, however, use a BMI measure to place the child in a percentile, rather than a weight category. ACTIVITY Go to the following web page and explore the charts and surrounding information on the CDC website. http://www.cdc.gov/growthcharts/cdc_charts.htm Childhood and adolescent nutrition: Common issues Overweight and Obesity In the developed world, overweight and obesity present a major health issue. One in four Australian children are overweight or obese, with even distribution between boys and girls. Carrying excess weight in childhood increases the likelihood of psychological issues and poor self-esteem, and developing conditions such as type 2 diabetes, hypertension and issues with joints (especially weight bearing joints) in adulthood. It is also recognized that overweight children are more likely to be overweight in adulthood than their healthy weight counterparts. Excess weight gain in adults and children has many causal factors. Ultimately there is an imbalance in energy balance, but there are many factors that effect this system. A genetic predisposition can contribute towards weight gain, but an ‘obesogenic environment’ is thought to play a much larger role. Frequent consumption of energy dense foods, such as products high in fat (yet low in other nutrients), high sugar beverages and many snack foods marketed at children or parents of children contribute towards an excessive energy intake. Larger portions are also implicated in weight gain in children. PSIO335. Lifespan Nutrition notes pg. 19 Sedentary lifestyles are a vital factor in the rise of overweigh and obesity. An increase in screen based entertainment and reduced incidental activity both contribute towards an environment that encourages inactivity as the norm. The figure below from Mann and Truswell (2012) outlines many of the factors associated with excess weight gain in children. ‘Treating’ obesity in children requires a holistic approach, where the environment, learned behaviours, peers, and especially family must be considered. Providing treatment in the context of the family is vital, with parental education and strategy setting preferred by most health professionals. For most children, it is not appropriate for weight to be ‘lost’, but rather for weight to maintained as height increases, allowing children to ‘grow into’ their weight. READ The following article from choice.com.au discusses the issue of ‘junk food’ marketing towards children. https://www.choice.com.au/shopping/packaging-labelling-and-advertising/advertising/articles/junk- food-advertising-to-kids Allergy/intolerance A food allergy is an inappropriate response of the immune system to a food. In most cases, IgE antibodies are produced to ‘fight off’ the foreign substance. This will usually result in the release of histamine which causes inflammation. The most common allergens in Australian Children are cow’s milk, eggs, nuts, soy and wheat, however many children grow out of their allergy by the age of five. Symptoms of food allergies can range dramatically from quite mild to life threatening. Swelling and inflammation, hives, gastrointestinal symptoms, swelling of respiratory tract, blocked/runny nose and sneezing are all common, while there are many cases where anaphylaxis can result. Anaphylaxis is a severe allergic response. While not all cases will experience the same signs and symptoms, these can include: Flushed skin and/or hives Swelling of throat and mouth Difficulty breathing or speaking Severe asthma Weakness or collapse Gastrointestinal pain/nausea/vomiting Unconsciousness Food allergies are managed by simply removing the culprit foods from the diet. In all cases it must be ensured that the food avoidance does not leave a ‘gap’ in the child’s diet. For example, a child with a cow’s milk allergy must remove all milk products from their diet. These should be replaced with appropriate alternatives, such as calcium fortified soy milk or lactose free milk to continue to provide adequate protein, calcium and other vitamins and minerals. PSIO335. Lifespan Nutrition notes pg. 20 Children with severe food allergies must be carefully managed. Education for the parent and child will be provided, and a management plan will be put in place at the child’s school. This will usually include the placement of an Epipen in the school or classroom for use in an emergency. Many schools are also becoming ‘nut free’ to limit the risk allergic reaction in students who are identified as having a nut allergy. Food intolerances are a collection of different reactions. They are non-immune responses to ingested food that can range from perceived discomfort after eating certain foods or substances, through to diagnosable conditions such as Coeliac disease or lactase deficiency. While some of these conditions must be diagnosed through medical testing (e.g. a small bowel biopsy to diagnose Coeliac Disease), investigation and diagnosis is often completed through food based elimination and subsequent food ‘challenges’. It is important that these investigations are carried out by a trained dietitian as there are many factors that must be considered. There are many testing methods that are not considered to be accurate or effective. These should be avoided as they are often expensive and can delay access to appropriate treatment. As with allergies, the current management of intolerances is to avoid the foods that cause symptoms. In some cases there are products available that correct the initial problem, allowing for subjects to consume the foods that initially caused difficulties. An example of this is the introduction of lactase enzyme products to allow people with a lactase deficiency to consume milk products. There is also research into a treatment for Coeliac disease, however the mechanisms behind many intolerances is unknown, making it difficult for treatment options to be generated. Dental health Dental decay is a widespread health issue among children, with one in two Australian 12 years olds having some form of tooth decay in their adult teeth. Dental decay occurs as a result of three interacting factors – sugars, bacteria and the tooth. These sugars, when they remain in the mouth, are fermented by oral bacteria. This fermentation process produces acidic compounds that demineralize the tooth enamel, which in time can lead to decay of the tooth. The impact of sugars is based largely around the length of time that the sugars are in contact with the tooth, as well as the type of sugars. ‘Sticky’ sugars, such as hard/chewy lollies, muesli bars, honey and some dried fruits, and sugary beverages, such as soft drinks, sports drinks or flavoured milks are higher risk foods as the sugars stay in contact with the tooth for longer. It is recommended that if these items are consumed, they are consumed with meals (and that teeth are brushed after the meal), rather than in between meals where the sugars are able to remain in contact with the tooth for prolonged periods. Prevention is mainly centered around reducing or removing one or more of the three factors implicated in dental decay. Strategies can include: Dietary change – reducing frequency of sugar consumption, and avoiding ‘sticky’ type sugars that remain on teeth Avoiding bottle feeding infants as they go to sleep (teeth remain ‘bathed’ in sugars overnight). PSIO335. Lifespan Nutrition notes pg. 21  Avoiding putting any liquids other than plain milk/formula or water in infant bottles. Encouraging regular teeth brushing to minimize bacterial growth (twice daily recommended). Drinking fluoridated tap water to control bacterial numbers and strengthen tooth enamel. Receiving regular dental check ups to monitor for signs of early decay and implementing required treatment to prevent further development or complications. Chronic disease In recent years, chronic diseases once thought only to be adult onset diseases, have been increasing in prevalence in adolescents. Earlier onset of Type 2 diabetes has been evident, along side the increasing weight of Australian children. Signs of cardiovascular disease have also been observed in adolescents, which may in time lead to decreasing age of onset of these diseases. Although still relatively uncommon, cancer causes the most deaths in children of all chronic diseases. The most common cancers in children are leukemia and brain/CNS cancers. Mental health conditions are also on the rise, with 14% of children between the age of seven and 14 observed to have had some form of mental health condition within the past year in one study. Childhood and adolescence is a crucial time for developing healthy lifestyle habits that will reduce the risk on chronic disease onset. Pregnancy in teenage years Nutritional assistance in pregnancy is essential for promoting healthy outcomes for the mother and baby. Maintaining an adequate BMI, supplementing and monitoring essential nutrients (such as folate, iron, calcium and vitamin D) and monitoring the baby’s growth and development can all be vital in reducing risks in pregnancy. Other lifestyle factors such as not smoking or drinking alcohol, and avoiding foods with a greater risk of food poisoning are also an important as part of the education required. It can be difficult however, to target, educate and assist this group, as many adolescent pregnancies are unplanned, or surrounded by secretive tendencies with can interfere with appropriate assistance and care being sought. 3. Elderly Nutrition in older people In Australia, as well as the rest of the developed world, the population is growing older. Between 1994 and 2014, the proportion of 15-64 years olds has remained fairly stable, while those over 65 PSIO335. Lifespan Nutrition notes pg. 22 years increased from 11.8% to 14.7%. This trend is expected to continue, but at a greater rate over the years to come. Australian population structure, by age and sex Aging is an inevitable and natural process. Developing healthy lifestyle habits including good nutrition and being physically active may lower the risk of disease in later life and improve the quality of life. While the Australian Dietary Guidelines are applicable older Australians, there are some specific dietary considerations that must be made. Energy Energy needs decrease at a rate of approximately 5% per decade after the age of 50. This is accounted for by a general decrease in metabolism, a decrease in muscle mass and a decrease in physical activity. Careful meal planning is essential as nutrient needs must be met consuming fewer calories. Weight gain should generally be avoided, however a small amount of weight gain may be beneficial, as studies show death rates for 70-75 year olds are lowest for those in the overweight category. Those in the obese category did not have the same beneficial results. It is prudent to adjust the BMI rankings when assessing people over 65 years to allow for this. Although there is no universally agreed on adjustment, the following table represents a widely used option. PSIO335. Lifespan Nutrition notes pg. 23 BMI ranges for people over 65 years Underweight 71yrs decreases with age. It is also common for older people to have sun exposure. Vitamin B12 Needs increase (no change The ability to absorb in RDI) naturally occurring vitamin B12 in food decreases with age. Synthetic forms of the vitamin are better PSIO335. Lifespan Nutrition notes pg. 25  absorbed as they are not bound to a protein carrier. Calcium Needs increase An adequate calcium intake is one way to RDI = 1300mg/day. protect against osteoporosis, yet many older people do not consume enough. Water Needs increase Some common medications and caffeine increase water losses. Older people may choose to drink less fluids to avoid frequent urination. Changes to body composition and eating patterns In many older adults, body composition changes. Usually a loss in lean tissue and bone mineral are evident, with a concurrent increase in fat tissue. The loss of lean muscle mass can be combatted by undertaking strength training and ensuring regular weight bearing activity, such as walking. A decrease in appetite is also common, which may be linked to the common deceased lean body mass and physical activity. This along with slowed digestion may mean that smaller, more frequent meals are more appropriate. Other key functional issues that can inhibit or alter food consumption in older age include dental issues, and the ability to swallow foods successfully. Limited chewing or swallowing may call for foods that are altered in texture, for example, minced meats or boneless fish may be more appropriate that a steak or chicken breast if the subject is having difficulty chewing, while a thickener may be suitable for a client having difficulty swallowing thin fluids such as water, juice or tea. These thickeners are available commercially with the specific purpose of assisting clients with dysphagia. Cognitive barriers may also be present, with older people forgetting when to eat (or if they already have eaten), what they should eat or how to cook or how to use simple kitchen appliances. It is also common that older people revert to a simple diet (for example tea and toast for most meals) as they have limited energy for preparation of more substantial meals. In these cases, in home care can be of assistance, as can a meal delivery service (such as ‘Meals on Wheels’). Nutrition assessment Assessing nutritional status in older adults is vital for ensuring that appropriate nutritional care is provided. Weight or BMI monitoring can be used to assess changes over time if no issues are foreseen, however, in cases where malnutrition is suspected various tools are available for PSIO335. Lifespan Nutrition notes pg. 26 screening. The most widely used tool in Australia is the Mini Nutritional Assessment (MNA) released by the Nestle Nutrition Institute. This tool uses anthropometric measurements as well as simple questions that can be answered by the subject, a family member or carer to assess status. This tool, and others like it, can identify elderly people who require additional nutritional input, either from dietary advice, assistance with meals or shopping, or nutritional supplements. In cases where malnutrition is observed goals of care are different to those of the general population of older adults. Weight gain and maintenance are often achieved through: Increasing protein intake (this is especially important if illness or skin wounds are present) Increasing energy intake Promoting fluids, including energy containing fluids. Encouraging regular small meals (especially as large meals can be overwhelming when appetite is limited) Assisting with over coming physical barriers (e.g. promoting use of fish, mince and other softer meats if chewing is difficult, ensuring assistance at meals if self feeding not possible). Assisting with overcoming psychological barriers – especially important if signs of dementia or memory loss are present (e.g. setting alarm as a reminder for meal times) Meal preparation assistance where required (e.g. Meals on Wheels community meal delivery, home nursing assistance) Supplements For older adults who are malnourished or at risk of malnutrition, specialist dietary advice is required to prevent further weight loss and promote well-being. There are many supplements available for purchase that are designed to ‘fill the gaps’ of an insufficient diet. It is always preferable for an older Australian to meet their dietary requirements through the consumption of whole foods, however in cases where this cannot be achieved, nutritional supplements are a suitable alternative. These supplements tend to be high in energy (up to 8.4kJ per ml), high in protein, and provide additional vitamins and minerals. Certain supplements are also designed to contain fibre, however this is not always the case. There are many types of supplements including drinks, powders, puddings or tube feed supplements (for cases where the oral cavity is not able to be used). Specific products are available for certain conditions, such as diabetes, or renal disease as regular supplements may not have optimal nutrients for these groups. Some examples of common supplements used in Australia are included in the table below. Common supplements for use in malnutrition Supplement Features Uses Ensure Plus, Abbott Ready to drink Unintentional weight loss Nutrition Inadequate oral intake. PSIO335. Lifespan Nutrition notes pg. 27  237ml serve = 13g Can be used as complete protein, 1479kJ, many nutritional product vitamins and minerals Contains milk and soy Not fibre fortified. Ensure Enlive, Abbott Ready to drink Unintentional weight loss Nutrition Inadequate oral intake. 237ml serve = 20g protein High protein needs (e.g. + HMB, 1479kJ, 3g fibre, wound healing) many vitamins and minerals. Contains milk and soy. Fortisip, Nutricia Ready to drink Unintentional weight loss Inadequate oral intake. 200ml serve = 12g protein, Gluten and/or lactose 1260kJ, many vitamins intolerance and minerals Gluten and lactose free. Resource 2.0, Nestle Ready to drink Unintentional weight loss Inadequate oral intake. 237ml serve = 20g protein, 1990kJ, many Fluid restriction (e.g. with vitamins and minerals. renal disease). Low in sodium/ potassium. Contains milk and soy. Not fibre fortified. Sustagen Hospital Formula Powder form – must be Unintentional weight loss ‘made up’ Inadequate oral intake 60g serve = 13.8g protein, Should not be used as sole 954kJ, many vitamins and source of nutrition minerals. Can be mixed up with Contains lactose and soy. water for beverage form, Does not require or sprinkled on meals (e.g. refrigeration. cereal) for added nutrition. PSIO335. Lifespan Nutrition notes pg. 28 ACTIVITY Choose two supplements from the list above and complete your own online research surrounding these products. Compare the nutritional profile, as well as any special features the supplement may have (such as being lactose free or containing fibre) Drug-nutrient interactions It is important in all populations to consider drug-nutrient interactions when assessing nutritional intake and status. It is especially important to flag in the older population, as it is more likely that older adults will be taking medications, and more likely that more than one medication will be taken regularly, increasing the scope for drug-nutrient interaction. Also, as the body ages, its capability for processes and excreting medications is diminished. Interactions are also prevalent when using herbal or other alternative medicinal therapies, making it vital that all prescription, non-prescription and complementary therapies are reported to the client’ treating physician. Some ways that medications can interfere with nutrient absorption include: Damaging intestinal mucosa Changing gastrointestinal conditions (e.g. decrease or increase pH, alter secretions) Blocking methods of active transport for specific nutrients Increasing excretion of nutrients Even though some drugs have no biochemical method of diminishing nutritional absorption, oral intake can be limited due to the drug’s impact on consumption habits. Some medications are known to increase or decrease appetite, cause a dry mouth, or alter taste/smell perception of foods. Medications that cause drowsiness or a tremor can limit intake through the increased effort required for self-feeding. It is also important to note that medications causing nausea or vomiting will limit oral intake and absorption. PSIO335. Lifespan Nutrition notes pg. 29