Nutrition Throughout the Lifecycle Infancy, Childhood, and Adolescence. Life Health Promotion: Adulthud.
The nutrient requirements of humans are basically the same throughout the life span. What differs, depending on age, are the amount of nutrients required and frequency of food consumption (dietary patterns) recommended; these differences are caused by physiologic and psychosocial needs.
For example, consider the amount of food individuals are able to consume at one time. Toddlers can eat only small amounts at one time. They depend on planned snacks to provide their full assortment of nutrients. Adolescents, however, can eat large quantities but also need time throughout the day to eat. In contrast, older adults still have high nutrient needs but require less energy and therefore need more nutrient-dense foods.
The five dimensions of health also apply to the nutritioeeds of children and adolescents. Knowledge of the relationship between adequate nutrient intake and good health empowers children to practice health-promoting behaviors that enhance physical health. Children can use their intellectual skills to make decisions about their food choices. Caregivers should provide guidance for children to use food for nourishment and enjoyment, not as a means of emotional comfort. The social dimension of health is strengthened by including children in the preparation of food, which teaches children the social skills of cooperation. The spiritual dimension is developed by sharing meals with others as a form of communication and bonding.
NUTRITION DURING INFANCY
Energy and Nutrient Needs during Infancy
Dramatic changes in growth and development occur during the first 12 months of life. In the first year, a human infant is expected to triple its birth weight and increase its length by 50%. In addition, after birth, organs such as the kidney and brain continue to develop and mature. Io other period of life do growth and development occur so rapidly. To support this rapid growth and development, the appropriate balance of all nutrients is essential. At the same time, parents, caregivers, and healthcare professionals must realize that infants have specialized nutrient needs. Advice appropriate for adults, and even older children, is inappropriate for infants, particularly with regard to fat and fiber intake and weight gain patterns.
Energy
The World Health Organization suggests that infants receive 108 kcal/kg/day for the first 6 months of life and 98 kcal/kg/day from 6 months until the first birthday.
Adequate energy intake will be reflected in satisfactory gains in length and weight as plotted on a National Center for Health Statistics (NCHS) growth chart. Infants should not have a restricted fat intake. Well-meaning parents should not place their infants on low-fat diets. Human milk, in fact, is high in cholesterol and fat content. Omega-3 fatty acids are plentiful in human milk, particularly if the mother includes fish in her diet on a regular basis. These fatty acids have been found to be essential for proper brain and nervous system development.
Protein
Proteieeds of infants have been hard to determine because of the difficulty of performing nitrogen balance studies on this population. Requirements are estimated based on the intake and growth rates of normal, healthy breastfed infants.
Protein requirement is highest during the first 4 months of life when growth is the most rapid. It is suggested that infants receive 2.2 g/kg/day from birth to 6 months of age and 1.6 g/kg/day for the second half of the first year.51 An excess of protein in an infant’s diet can be problematic. Protein has a significant influence on renal solute load. The infant kidney is immature and unable to handle the large renal solute loads of an adult. Therefore increasing a normal infant’s protein intake above the recommended amount should be avoided.
Vitamins and Mineral Supplementation
The DRIs may be consulted for appropriate levels of vitamins and minerals for infants.
Breast milk or commercial formula should provide infants with all the vitamins and minerals needed for proper growth and development.
During the third trimester of pregnancy, the fetus stores iron in its liver to be used during the postnatal period. By 4 months of age, this supply of iron is usually depleted. The iron in breast milk, although lower in absolute amounts, is more bioavailable than iron from commercial formula. Many breastfed infants do not need to be supplemented with iron.
However, their iron levels should be assessed periodically. Infants who consume commercial formula should use the iron-fortifiedvariety to prevent iron deficiency anemia.
Humans are able to manufacture vitamin D through exposure to the sun; many young infants may not receive enough sun exposure for adequate synthesis. Breast milk contains vitamin D, but it may not be present in levels sufficient to prevent vitamin D-related rickets. There are several documented cases of vitamin D-related rickets, particularly among fully breastfed infants who receive little or no sunlight exposure.
Therefore it is recommended that all breastfed infants receive a daily oral supplement of vitamin D, unless they receive substantial sunlight exposure. Vitamin D can be toxic, so the recommended dosage should not be exceeded. Because vitamin D is present in commercial infant formula, formula-fed infants need not receive a supplement. Use of milk alternatives such as rice beverage (“rice milk”) and soy health food beverage have also resulted in rickets. These alternatives, which are low in protein, calcium, and vitamin D, are not nutrient dense in comparison with breast milk, formula, or cow’s milk.
Healthcare providers need to emphasize to caregivers that although the term “milk” is used in reference to these beverages, they are not nutritionally equal to milk produced by humans or by animals.
The water supply of most major cities in the United States contains fluoride as a preventive measure against tooth decay. The availability of fluoride may be particularly important for infants and young children whose teeth are developing. Routine fluoride supplementation is not recommended for infants less than 6 months of age.
Older infants may need to receive fluoride if their local water supply is not fluoridated, but an assessment of total exposure to fluoride (via water, or juice prepared from local water source) should be made before systemic fluoride is prescribed.
For example, many rural families who rely on well water should have water supplies assessed for fluoride content. Excess fluoride can result in fluorosis, or mottling of tooth enamel; consequently the dosage should be followed precisely.
Newborns are vulnerable to vitamin К deficiency (and thus hemorrhaging) in part because they lack intestinal bacteria to synthesize the vitamin. As a preventive measure, U.S. hospitals routinely give infants 0.5 to 1.0 mg of vitamin К by injection or 1 to 2 mg orally, once shortly after birth.
Food for Infants
The ideal food for the first 4 to 6 months of life is exclusive use of breast milk. As mentioned previously, breast milk has the correct balance of all the essential nutrients as well as immunologic factors that protect the infant from acute and chronic disease. The breast should be offered at least 10 to 12 times per 24 hours in the first several weeks. As the infant develops a stronger suck, more milk will be extracted with each nursing session and the frequency of feeding may decline. Although there is no specified time the infant should stay on the breast, between 10 to 15 minutes per breast (offering both breasts per session) is a good recommendation. It is important to realize this is a general guideline because all infants have different nursing styles. It may in fact be more appropriate to watch the infant—not the clock— in an effort to allow the infant to dictate when satiety is reached. The Teaching Tool box offers some suggestions to facilitate successful breastfeeding.
If a mother chooses not to breastfeed or if she has a medical condition contraindicating breastfeeding, a variety of formulas made from either cow’s milk or soy are available. In addition, a number of specialty formulas, such as protein hydrolysate formulas, are available for infants with medical problems. The parents should consult their primary healthcare provider or nutrition care specialist to identify the most appropriate formula for their infant.
Formulas are either ready-to-feed, where no mixing is required, or are a powder or liquid concentrate to be mixed with water. To reduce the chance of lead leaching into water, tap water should be run for 2 minutes after it has been standing in the pipes and only cold water should be used for formula preparation. The formula should be mixed exactly as stated on the package, unless otherwise directed by a primary healthcare provider. Adding insufficient water can result in a high renal solute load, placing strain on the immature infant kidneys; overdiluting will precipitate undernutrition.
For parents or caregivers who may be non-English speaking or have low literacy skills, pictorial mixing instructions may be useful. Alternatively, asking the caregiver to demonstrate appropriate formula mixing may be suitable. Formula should never be heated in a microwave oven because microwaves heat food unevenly. Contents of a bottle appearing to be cool on testing may actually have portions that could scald an infant. All unused formula at the end of a feeding should be discarded if not used within 2 hours because of contamination by saliva enzymes and bacteria. Homeprepared formulas made from evaporated milk, popular in some cultures, are likely to be low in iron, vitamin C, and other essential nutrients and should be avoided.
Before 1 year of age, cow’s milk, regardless of fat content or form (evaporated, liquid, or dried), should not be fed to infants. The fat in cow’s milk is less digestible than the fat in breast milk or formula and contains less iron and more sodium and protein. These higher levels of solutes may lead to dehydration caused by increased urine volume to reduce solute levels in the body. Deficiencies of other nutrients, such as vitamin C, essential fatty acids, zinc, and possibly other trace minerals, develop because cow’s milk is a poor source of these nutrients.
Cow’s milk may be introduced after 1 year of age when at least two thirds of energy needs are fulfilled by foods other than milk. The delay in cow’s milk consumption reduces the risk of developing a milk allergy. Reduced fat and nonfat milk is not recommended until age 2.
Introduction of Solid Foods.
Solid foods may be added to the infant’s diet between the ages of 4 and 6 months. Infants who are introduced to solid foods before this time may be prone to excessive kcaloric intake, food allergies, and GI upset. Many parents and even some healthcare professionals believe offering an infant cereal in the evening will promote sleeping through the night. This belief, however, is not supported by research.
There are two basic issues when considering the introduction of solid foods to the infant’s diet: (1) how to introduce them and (2) what to introduce.
How to Introduce Solid Foods.
Parents and other caregivers may be anxious to introduce foods other than breast milk or formula to their infant’s diet. Health professionals can assure them that it’s best for the infant to be developmentally ready for solid foods. The infant should be able to sit with some support; move the jaw, lips, and tongue independently; be able to roll the tongue to the back of the mouth to facilitate a food bolus entering the esophagus; and show interest in what the rest of the family is eating. For example, the infant may try to reach and grab an item off of a family member’s plate at mealtime. Likewise, parents should become familiar with satiety cues so as not to overfeed the infant. To indicate fullness the infant may turn her head to the side, refuse to open her mouth, or grimace when the spoon comes close to her mouth. The caregiver should respect these cues. The infant should never be force-fed. If the infant is overtired or is not interested in food, she ought to be removed from the high chair and the foods offered again later.
When an infant reaches the age of 9 to 12 months, he may enjoy self-feeding.
Although this may be a messy process, caregivers should encourage the development of these skills through food exploration.
Appropriate Solid Foods during the First Year of Life.
The second half of the first year of life should be thought of as a transitional period; breast milk or formula is still the primary food, and the solid foods are complementary. Solid foods should be introduced gradually and one at a time with a 4- to 5-day interval between new foods. This timing is crucial because if the infant has any type of allergic reaction such as GI upset, upper respiratory distress, or skin reactions (e.g., eczema, hives), the offending food may be easily identified. Families with a documented history of allergies should delay introduction of solid foods until the infant is about 6 months old. If solid foods are introduced too early, the large protein molecules of the offending food may cross the intestinal barrier and elicit an immunologic response in the infant. As the gut matures, it is less likely to allow large unhydrolysed proteins to cross the mucosa.
Solid foods offered to the infant need not be commercial. Home-prepared foods are a good, practical alternative. There should be strict attention to sanitary food preparation procedures. Although infants should not be offered excessive sweets, naturally sweet fruits such as peaches offer them a taste satisfaction. Although salt should not be added to an infant’s food, complete elimination of sodium from foods in the diet is neither practical nor recommended.
A variety of textures, colors, and tastes is important for infants, whether they receive home prepared or commercial infant foods.
Beverages during the First Year of Life.
Fruit juice, particularly apple juice, is offered to many infants. Fruit juice can make an important contribution to the diet as a source of vitamin C, water, and possibly calcium. Its use, though, may need to be monitored. Excess fruit juice (greater than
Special Nutritional Needs
The nutrition requirements of children with congenital or acquired health problems deserve special attention. These infants often have increased nutrient requirements, increased losses, or malabsorption. Significant drug-nutrient interaction often takes place as well. Although it is beyond the scope of this chapter to describe all of the children’s special needs one might encounter in practice, a few of the major disorders are outlined. In all of these cases, a registered dietitian should be a part of the medical team.
The Premature and Low Birth Weight Infant
An infant is considered premature if he or she is born before 37 weeks’ gestation.
Low birth weight infants may be full term or premature but weigh
Because the coordinated suck-swallow reflex is not fully developed until an infant reaches 34 weeks’ gestation, initial feeding of the premature infant may need to be via total parenteral nutrition, tube feeding, or gavage feeding. Many criteria influence the route of nutrient delivery, and thus each infant should receive an individualized nutrition assessment by a registered dietitian who specializes in highrisk pediatrics.
Premature infants have increased needs for protein, kcalories, calcium, phosphorus, sodium, iron, zinc, vitamin E, and fluids. The best feeding choice for a premature infant is mother’s milk with the addition of “human milk fortifier,” which adds additional minerals and proteieeded by the premature infant. Although the infant may not suckle well or may tire easily at the breast, the nurse can play a key role in helping the mother pump and store her milk in the neonatal nursery.
The milk may then be given by gavage even when the mother is not present.
If the mother chooses not to breastfeed, a variety of specialized infant formulas are available to meet the special nutritional requirements of the infant.
Recent research suggests these formulas should be fortified with long chain fatty acids to mimic what would be delivered via the placenta. Long chain fatty acids are essential for proper retinal and neurologic development. Premature and low birth weight infants require continual nutrition follow-up after discharge for at least the first year of life because they are at risk for feeding problems, developmental delays, and growth retardation.
Cystic Fibrosis
Cystic fibrosis (CF) is an autosomal recessive disorder and is the most common genetic disorder among Caucasian populations, affecting roughly
The chronic pulmonary dysfunction leads to malnutrition caused by an increased metabolic rate, increased energy requirement, and frequent use of antibiotics, which can cause anorexia. Steatorrhea, maldigestion, and malabsorption are common because of the lack of lipase secretion in the pancreas. Because of these increased needs as well as greater losses, patients are not always able to meet nutritioeeds.
To prevent frank protein and energy malnutrition and resulting growth failure, the Consensus Committee of the Cystic Fibrosis Foundation recommends all CF patients receive a comprehensive nutrition assessment every 3 to 4 months. Care of the CF patient should be multidisciplinary, and each nutrition assessment plan should be individualized to promote optimal growth and development.
Failure to Thrive
Failure to thrive (FTT) is defined as a fall of two standard deviations in weight gain over an interval of 2 months or longer for infants less than 6 months of age or over an interval of 3 months or longer for infants greater than 6 months of age.
An alternative definition is a weight-for-length measurement less than the fifth percentile or weight for age below the third percentile.
FTT may have organic causes such as an underlying metabolic disorder. Congenital heart disease or HIV infection may cause such an increased energy requirement that oral intake is not able to keep up with metabolic need.
Nonorganic FTT may be diagnosed when no medical reason for poor growth can be recognized. There may be psychosocial causes of the FTT such as inadequate maternal-infant bonding, poverty, child abuse, or neglect. Treatment for nonorganic FTT must include nutrition intervention to promote weight gain and therapy to correct developmental delays and any psychosocial problems in the home environment
Inborn Errors of Metabolism
Phenylketonuria.
All 50 states have newborn screening programs to detect
PKU. When discovered early, dietary therapy can begin immediately and longterm prognosis is good. Without treatment, phenylalanine and its metabolites reach toxic levels in the blood, resulting in damage to the central nervous system including mental retardation. Likewise, because phenylalanine cannot be converted to tyrosine, low or absent tyrosine may contribute to the mental retardation.
Treatment consists of a low-phenylalanine diet to be followed throughout the individual’s life. In infancy the use of a special formula such as Lofenalac is recommended.
Partial breastfeeding is permitted, but phenylalanine levels in the infant’s blood must be monitored carefully.66 As PKU children are introduced to solid foods and make the transition to table foods, meals require careful planning. The use of low-protein breads and pastas is advised. This condition requires close monitoring of dietary intake by specialized dietitians.
Galactosemia.
Galactosemia is another rare, autosomal recessive disorder caused by an enzyme deficiency and is part of the newborn screening panel. Absence of the enzyme galactose 1-phosphate uridylyltransferase results in an inability to metabolize galactose. Because the milk sugar lactose is a disaccharide of glucose and galactose, these infants are unable to tolerate any milk products containing lactose. Manifestations include diarrhea, growth retardation, and mental retardation. Treatment is dietary therapy excluding all milk products, including human milk. Soy formulas and casein hydrolysate formulas are acceptable. Even with lifelong diet therapy, there may be long-term health consequences such as nervous system or ovarian dysfunction.67 Specialized pediatric dietitians closely monitor the diet of infants and children who have this disorder.
Other inborn errors of metabolism requiring nutrition therapy include urea cycle disorders, maple syrup urine disease, and homocystinuria.
Life Span He alt>
romotion: Childhood
and Life Span Health Promotion: Childhood and Adolescence
Stages of Development
The life span stages reflect psychologic and physiologic maturation. Approaches to health promotion take into account these stages and their impact outrient requirements, eating styles, and food choices.
Childhood (1 to 12 Years)
The accelerated growth of infancy slows down by about age 1, marking the transition to childhood. Growth then occurs unevenly until puberty heralds the onset of adolescence. This growth deceleration during childhood results in varying hunger levels that reflect physiologic need. Awareness of these fluctuations by parents and caregivers allows children to stay in tune with their internal hunger cues.
Nurses sensitive to normal growth patterns as affected by genetics and environmental influences can assist families to understand the growth curves of their children.
Height, weight, and head circumferences are used with the standard growth charts from the National Center for Health Statistics to monitor growth.
Childhood categories are based on a combination of psychosocial and physiologic developmental stages. Physiologic requirements are the basis of the age and gender divisions of the Dietary Reference Intakes (DRIs). This discussion highlights the nutrients of concern-protein, iron, calcium, and zinc. For other specific agerelated nutrient recommendations, refer to the DRI tables inside the front cover.
Although adults may have predominant influence over the eating behaviors of children, another primary influence for some children is television. The influence of TV commercials has been studied extensively and is most often condemned as negatively influencing children’s food choices. In addition, watching television when eating family meals appears to impact the types of foods served, which results in consumption of foods higher in fat and lower in fiber. This possibly reflects the categories of foods most often advertised on television. Parents and caregivers can watch television with their children to assess the type of products advertised and then discuss their nutritional value. As more healthful products are marketed, even if targeted at adults, acceptance by children may increase. Occasional treats of advertised products may lessen their appeal if children are accustomed to highquality snacks and meals.
The recommendations given by the Dietary Guidelines for Americans are considered appropriate for ages 1 through 10, particularly in regard to fat intake; 30% kcal from fat or less is the general goal for the population at large. A level of about 30% may also assist with obesity prevention and emphasize fruits, vegetables, and complex carbohydrates. It is easier to enjoy whole foods that are naturally low in fat throughout childhood than to convert one’s eating style as an adult. The American Heart Association, the American Health Foundation, and the National Institutes of Health Consensus Development Panel recommend application of the 30% goal to the age group from years 1 to 2 and older.
The Committee on Nutrition of the American Academy of Pediatrics, however, has expressed concern that 30% or less of kcalories from dietary fat would overly increase the intake of bulky plant foods, possibly precluding consumption of enough nutrients by young children. Consequently, the Committee accepts a 30% to 40% dietary fat intake for age 2 and older.4 Levels higher than the 30% to 40% recommendation may actually cause fat to crowd out other nutrients.
Despite national dietary recommendations, the U.S. Department of Agriculture’s Continuing Surveys of Food Intakes by Individuals (1989-1991) reveals that for children ages 2 to 11, the average number of servings per day was below the minimum recommendations for all food groups except for the dairy group. Roughly 16% did not meet any food group recommendations, whereas only 1% consumed recommended amounts for all food groups. Those who did meet dietary recommendations had intakes that were high in fat. These findings indicate that nutrition education is still needed for parents and their children.
Health professionals need to use careful wording when discussing nutrient restriction or reduction for children. Several infants have developed failure to thrive, not because of neglect or lack of food, but because of parental overzealousness about fat, both dietary and body.
Stage I: Children 1 to 3 Years Old
Usually referred to as “toddlerhood,” the age span of 1 to 3 years old is a busy
time for young children. They are dealing with issues of autonomy. Often food and eating create an arena for asserting newly discovered independence. The eating relationship between parent (or caregiver) and child is forming, and adult reaction to autonomy sets the stage for future encounters.1 Consistency of mealtimes is important.
Meals are best accepted when hunger, tiredness, and emotions are still controllable; an overly tired child just cannot eat. Equally important is fostering self-reliance by allowing young children to feed themselves in a manner most appropriate for their psychomotor abilities. Regardless of the messy results, attempts to self-feed provide the roots of self-empowerment crucial to overall physical and psychologic development.
Hunger, rather than adult meal schedules, guides the child’s perception of time to eat. Meals for toddlers are based on the same design and food selections as adults, only in smaller portions. (Of course, overly spicy foods may not be acceptable to young taste buds.) Snacks are a necessity in addition to meals. Toddlers are able to eat only small amounts at each meal or food encounter. Planned snacks provide required additional nourishment between meals to ensure an adequate dietary intake.
Nutrition Requirements.
Growth, basal metabolic rate (BMR), and endless activity require an energy supply of 1300 kcal/day for ages 1 to 3. Proteieeds increase to
This age span of 1 to 3 years old is the time to begin introducing lower-fat versions of commonly eaten foods. As previously mentioned, fat-containing foods should not be obsessively restricted; however, high-fat foods are often filling and may displace other nutrient-containing foods.
This is also a prime time to introduce toddlers to a variety of foods. Toddlers imitate the adults around them. Therefore adults can model behavior by eating a variety of foods themselves. Clever introductions to foods are always helpful to catch the attention and appetite of toddlers. Broccoli is not just a vegetable; cut up, it looks like little trees. Peas steamed in their pods are not just peas but green pearls waiting to be discovered.
Although breast milk or formula is the milk of choice until age 1, toddlers should drink breast milk, whole milk, or formula until age 2, after which low fat or skim milk is best. Sometimes toddlers consume too much milk or juice, particularly if they are given an unlimited number of servings. Perhaps drinking
from feeding bottles throughout the day simply becomes a habit. Unfortunately, the child fills up on milk or juice, both low sources of iron, and then does not have an appetite for iron-containing foods such as meat, fish, poultry, eggs, or legumes. Iron deficiency anemia may develop. Additionally, apple juice is sweet tasting and has few nutrients beyond carbohydrate kcalories. Frequent consumption may habituate young children to sweet drinks. Later, apple juice may be replaced with sugar-laden sodas, which displace more nutrient-dense beverages.
One possible solution is to dilute juices with water. Milk can be served with meals and diluted juices drunk between meals. Parents and caregivers can view bottles as cups or glassware. Few of us drink from a cup continuously while watching television, reading, or playing games. Similarly, once past infancy, young children’s use of feeding bottles should be viewed as beverages, with the use of cups encouraged.
Stage II: Children 4 to 6 Years Old
The stage of 4 to 6 years old is characterized by independent eating styles, although modeling of adults still occurs. Children of this age clearly understand the time frame of meals and can save their appetite for meals. Snacks are still an integral part of the child’s nutrient intake. Far from the messy eating styles of toddlers, these children accept foods more easily if presented separately, not mixed in a casserole style. Variations of hunger and appetite levels may confuse parents and caregivers. The most practical approach is to be respectful of these variations of hunger; this diffuses power plays over food consumption.
New foods can continue to be introduced. For some families, back-up meal plans can encourage trying new foods. For instance, if a child does not accept a new dish after a reasonable attempt, the child may be allowed to prepare a meal of a peanut butter sandwich or cereal and fruit. By establishing back-up meals in advance, parents avoid becoming short-order cooks preparing three or more individualized meals for dinner.
Another approach is to have at least one meal (eaten at home) include new foods along with favorite foods. When the child looks at his or her plate, he or she recognizes some familiar foods in addition to the new foods. A meal can consist of a sampling of food items; several will probably be acceptable.
At this stage children can develop a sense of responsibility for healthful food selections.
They can understand that although all foods are okay, some foods such as fruits, vegetables, and low-fat foods can be eaten more often than others. After participating in a 3-month nutrition education demonstration project to decrease cholesterol and cardiovascular risk, some of the children ages 4 to 10 reduced their caloric intake of fat by about 9 percent by replacing higher fat food with lower fat foods within the same food group. These same children also increased their overall intake of fruits, vegetables, and very-low-fat desserts. Their total calorie and nutrient intake remained appropriate.
Sometimes children develop food jags, wanting to eat only a narrow range of foods. Parents and teachers can educate the child that each food contains a different assortment of nutrients and offer substitute choices that contain additional nutrients, with the child making the final selections. Eventually food jags diminish and the child consumes a broader selection of foods.
Nutrition Requirements.
Energy requirements jump to 1800 kcal/day at 4 to 6 years of age, reflecting continued growth and activity levels. Proteieeds increase to
Stage III: Children 7 to 12 Years Old
The years from 7 to 12 are tumultuous. Although actual growth may slow down, the body is preparing and seemingly storing up for the puberty growth spurt. Puberty may begin for girls from around age 9 and on; boys may reach puberty in the early teen years. This prepuberty time may be reflected by weight buildup; an increase in chubbiness is not alarming if moderate eating and physical activities are maintained. Adults must be careful not to overreact or they may plant the seeds of eating disorders. To rule out overeating, children can be asked if they are really hungry for food or if they are just tired or thirsty. These are different sensations.
A child can be reminded to “stop eating when you are full.” If hunger returns, a snack can be provided. By taking time to consider these sensations, children can stay in touch with internal cues of true hunger.
Exposure to other dietary patterns takes place as children spend more time away from home at school and socializing with friends. Peer influence at school lunchtime increases; having the right kind of lunch may be as important as wearing the right kind of clothes. Adults need to be sensitive to these issues. As long as a basic lunch of some protein, complex carbohydrates, and a beverage (preferably milk, juice, or water) is consumed, missing nutrients can be adjusted for later in the day, especially through after-school snacks.
It is at this age, when midmorning school snacks disappear and school lunch scheduling has more to do with numbers of students than with actual lunchtime appetites, that after-school hunger may intensify. This is the time to provide healthful snacks or at least stock the kitchen shelves with an assortment of nutrient-dense treats.
If children purchase snacks away from home, adults can develop guidelines with children this age to maintain positive eating styles.
Nutrition Requirements.
Energy needs for 7 to 12 year olds increase to 2000 to 2200 kcal/day. Protein requirements rise to between
Mineral needs increase as well. Because of increased bone growth and mineralization, calcium Adequate Intake (AI) recommendations jump from 800 mg/day at age 8 to 1300 mg/day throughout adolescence. Iron and zinc allowances increase as well. Well-chosen dietary intakes will provide sufficient amounts of these nutrients.
Marginal intakes of zinc have beeoted among school children who are finicky eaters; low zinc intakes can affect growth rates.
Childhood Health Promotion (1 to 12 Years)
Knowledge
The growth cycle of this age span is important for parents and children to understand.
Attention to issues related to weight, appropriate appetite, and meal patterning are crucial for the development of positive eating relationships and may prevent the development of eating disorders in the future. By understanding the relationship of nutrients and kcalories to their growth needs, children possess sufficient information to take responsibility for certain aspects of their food choices and dietary patterns. Children with special needs who are challenged by physical and/or mental limitations may require additional support to achieve nutritional adequacy. Ultimately, however, adults must provide nourishment for children and guidance as to positive health behaviors.
Techniques
Use of the Food Guide Pyramid to visualize and comprehend the variety and number of servings of foods that constitute a balanced nutrient intake works for both parents and children. A Food Guide Pyramid for Young Children ages 2 to 6 is now available. The “
Community Supports
Community supports for children are currently divided into two categories based on location and services or education offered: (1) school-food service and (2) classroom nutrition education.
School-Food Service.
The National School Lunch Program (NSLP) was established to protect the health and wellness of American children. Formalized in 1946, the program provides lunches at varying costs, depending on family income, to all school children at public and nonprofit private schools and residential child care institutions. At the federal level the program is administered by the Food and Nutrition Service (FNS) of the U.S. Department of Agriculture (USDA), at the state level by various agencies, and locally by school boards. As an entitlement program, the NSLP provides funds to all schools that apply and meet the criteria of eligibility.
Currently, more than 95,000 schools participate in this program.
Reduced-price meals are offered to children whose household income is below 185% of the federal poverty level; free meals are available to those falling below 130% of poverty. During the 1999-2000 school year, NSLP served meals daily to 26.8 million children. About 60% of these children received free or reduced-price lunches daily.
Specific nutrient guidelines regulate the meals served through this program. At times the definition of these guidelines has been controversial because of their nutritional impact on children and their economic impact on the farmers and food producers supplying the food. Some foods are available at reduced cost because of federal surplus commodities programs. Although wholesome, these may contain higher fat contents than would otherwise be used in the preparation of school lunches. Fresh fruits and vegetables may be passed over for canned fruits and vegetables that are not as acceptable to children and at times not as nutritious. Whole milk, cheeses, and high-fat meats may be served more often because of economics, despite the health objectives of consuming lower-fat foods. Meals served may not meet the lower fat and higher fruits and vegetable consumption recommendations of the Dietary Guidelines for Americans. Consequently, a Healthy People 2010 objective addresses this concern:
Increase the proportion of children and adolescents 6-19 years of age whose intake of meals and snacks at school contributes to good overall dietary quality.
Basically, lunch must provide approximately one third of the Recommended Dietary Allowance (RDA) and include the four food groups: dairy, protein, vegetables and/or fruits, and grains, bread, or pasta. For low-income children participating in the program, this provides one third to one half of their daily intake.
The School Breakfast Program was created in 1966 to support schools by providing morning meals in areas where children ride buses to school and/or most mothers are in the workforce, particularly in economically disadvantaged areas.
The program has reduced tardiness and decreased absenteeism. It is administered through the same governmental offices as the School Lunch Program and is also an entitlement program. During the 1999-2000 school year, 71,180 schools participated in the School Breakfast Program, serving 7.6 million children.
More than 80% of the participants qualify for free or reduced-priced meals. More than 42% of the children from low-income families receive both school lunch and school breakfast.
An assortment of foods can comprise breakfast, but the program requires milk (either as a beverage or with cereal), a serving of fruit (either whole or as juice), and two servings of a bread/cereal product or meat/meat alternative or a combination of bread and meat servings. The breakfast is designed to provide one fourth of the DRI.
During summer, the Summer Food Service Program for Children (SFSP) functions through a range of eligible organizations including schools, summer camps, and community agencies as well as various federal, state, and local government departments.
The purpose is to serve meals to school-age children when schools are not in session in communities where children depend on school meals as an essential component of their daily nourishment. During the summer of 2000, this program served more than 2 million children at 30,000 sites sponsored by 3600 organizations nationally.
School nurses and community health nurses should be aware of these programs as a valuable source of nutrition. Sometimes children do not participate because school payment policies create a stigma associated with participation. Intervention by a health professional may be required to ensure that children’s health needs are met in a socially sensitive manner. As health advocates, nurses may be able to highlight the importance of school lunch and breakfast programs to educational administrators and the community at large.
Classroom Nutrition Education.
Health has been taught for many years in most school systems. What vary are the depth of school health curricula and thequalifications of the instructors. Both may affect the quality of the nutrition education.
Although basic nutrition facts can be taught within a short-term health course, lifestyle changes that affect dietary patterns take longer to achieve. Unless they have special preparation, instructors may not feel comfortable teaching the intricate and ever-changing discipline of nutrition. This may lead to either poor quality teaching or the imparting of negative attitudes toward nutrition and food selections.
To further the goal of increasing the level of nutrition education throughout the country, a Healthy People 2010 objective addresses this concern within the school health curriculum:
Increase the proportion of middle, junior high, and senior high schools that provide school health education to prevent health problems in the following areas: unintentional injury; violence; suicide; tobacco use and addiction; alcohol and other drug use; unintended pregnancy, HIV/AIDS, and STD infection; unhealthy dietary patterns; inadequate physical activity; and environmental health.
Adolescence (13 to 19 Years)
The adolescent years are marked by change. Not only does puberty initiate growth acceleration, but emotional and social developmental struggles also occur as academic and personal responsibilities escalate. Adults often assume the attitude that teenagers can take care of themselves. Although teens need to take responsibility for their behavior and overall health status, they still need the guidance and nurturing of caring adults. There is a fine line between allowing adolescents to be responsible and neglecting their needs. Adult involvement is still necessary to provide physical and emotional support during the stressful years of adolescence.
Part of the physical and emotional support includes creating guidelines for dietary patterns and providing food for consumption. Creating guidelines means maintaining a household in which meals are available, even if family members may not be able to eat together. Knowing that dinner just needs to be reheated means someone was thinking of the welfare of all family members. Of course, shared responsibility for meal preparation may be an appropriate component of family duties.
A kitchen stocked with nourishing snack foods and ingredients for simple meals helps to make stressful, chaotic teenage schedules more manageable.
Older teens may be adjusting to the new demands of the college environment, including adapting to dining hall meals. Some campuses provide flexible meal plans with several locations for meal acquisition around campus. Others offer salad bars and food “stations” to provide a variety of selections. Individuals needing special dietary requirements such as kosher meals or lactose-reduced meals should discuss these issues with food service staff or with student service personnel.
As their sense of social awareness develops, some teens may adopt a vegetarian dietary pattern. Creative planning on the part of the teen and the family meal planner can result in meals that meet everyone’s nutritional needs without compromising personal convictions.
Discussions of the eating habits of teens tend to be critical of their fast-food consumption. Fortunately, most teens can afford the extra kcalories that typically higher-fat foods of hamburgers, fries, and pizza may contain. If teens have grown up accustomed to well-balanced meals, they will more than likely still prefer those meals to high-fat delights. Eating in fast-food restaurants, where prices tend to be inexpensive, may have more to do with socializing with peers than with nutrient values.
When fast foods become the mainstay of an individual’s diet, regardless of age, then some nutrients such as vitamin A and С may be lacking and overconsumption of dietary fats and kcalories may occur. Although teens may be seen at such restaurants, most other customers consist of families with young children as well as older adults. Fast foods affect the nutrient intake of all ages .
Nutrition Requirements
Because of the natural physiologic differences between adolescent males and females, nutrient requirements from age 9 and older are divided by gender. Females need about 2200 kcalories and
Calcium Al recommendations are the same for both genders, 1300 mg per day, to allow for skeletal growth (particularly for boys) and for bone mineralization, a prime physiologic function during adolescence. Bone mineralization for girls is a concern because teenage girls often underconsume calcium-rich foods.
Teenage girls and sometimes teenage boys are at risk for dieting-related disorders and eating disorders. By regularly underconsuming nutrients during a time when the human body is completing maturation, girls are at risk for various deficiencies as they progress toward adulthood and the nutrient requirements of potential pregnancies. In addition to calcium, iron allowances are important to fulfill, particularly for girls who begin menstruation; iron is also needed by boys, whose accelerated growth necessitates an increased blood volume and lean body mass.
Adolescence Health Promotion (13 to 19 Years)
Knowledge
The adolescent body benefits from a dietary intake most similar to an adult’s; however, some nutrient needs are greater. Energy requirements are higher than at any other time of life, especially for adolescents involved in competitive athletics. Calcium recommendations increase to ensure adequate mineralization of bones. Tolerance for alternative food styles enhances overall dietary intake and allows for the acceptance of dietary suggestions to maintain appropriate nutrient consumption.
Teenagers can comprehend the body’s physiology and nutrient needs. Ideally this information should be taught within family life, health, or science curricula in schools. This knowledge provides a rationale for consumption of nutrient-dense foods, especially as preparation for sport activities. Although adults may supply provisions for meals and snacks, especially those that can be reheated, ultimately most adolescents take responsibility for their owutrient intake.
Awareness of the risk factors and symptoms of disordered eating and drug/ alcohol abuse should be provided through health classes or interactions with health and educational professionals and parents. Even mild substance abuse in the face of the increased nutritional needs of adolescence can compromise nutritional status. For example, alcohol adversely affects absorption of folate and zinc, two nutrients required for normal growth. Nurses need to be aware of the indicators of substance abuse so they can guide adolescents into treatment.
Nutrition assessment, intervention, and support are part of comprehensive physical and psychologic rehabilitation of all substance abusers.
Techniques
Similar to techniques for children, the concepts of the Food Guide Pyramid and 5-A-Day provide a basis for adolescent food choices. Often the forces that override good food choices are lack of time and scheduling demands. One strategy accommodating both is to ensure the availability of simple meals that are easily eaten and reheatable. Scheduling of meals in a home or institutional setting (e.g., school cafeterias, dining halls) can take into account school, sports, work, and recreational agendas. To improve the quality of food choices, adolescents should be included in meal planning and food preparation.
OVERCOMING BARRIERS
Food Asphyxiation
Asphyxiation from food is possible at any point along the life span, but toddlers and older adults tend to be more at risk.
As toddlers first become accustomed to a variety of food textures and substances, they sometimes misjudge the size of food being chewed or may be too active when eating and accidentally swallow before sufficient chewing has taken place. Some foods that are potential problems are peanut butter (large clumps can stick in the throat), peanuts, popcorn, hot dogs, hard candies, gum, grapes, and foods containing bones (e.g., beef, poultry, fish). Efforts by parents and caregivers to serve appropriate foods to young children can prevent choking incidents. Children can be reminded to chew food well and sit quietly while eating.
Lead Poisoning
Lead poisoning can be an invisible health hazard. Found in old paint dust or chips, enameled porcelain fixtures (bathtubs), and soil or air from industrial and transportation pollution, excessive amounts of lead can be absorbed into the body.
Children are most at risk; they naturally absorb greater amounts of minerals than adults. Nutritional deficiencies of iron, calcium, and zinc tend to increase the absorption of lead. Lead poisoning and iron deficiency anemia are sometimes diagnosed concurrently. Excessive exposure to lead can permanently affect cognitive and perceptual abilities. These reduced functions affect learning ability.
Role of Nurses
School and community nurses in high-risk areas should be sensitive to this risk to both physical and intellectual health. High-risk areas for children include lower socioeconomic areas with poor housing conditions. Once lead poisoning is determined through blood testing, local health departments work with families to ascertain the sources of contamination in the home or school environment while physicians implement lead-reduction therapy.
Overall levels of lead in the environment are lower than in the past because of standards established and enforced by the Environmental Protection Agency. Levels of lead in some communities, however, are still high enough by Centers for Disease Control and Prevention standards that primary prevention activities to further reduce lead poisoning should remain a community-wide goal.
Obesity
The prevalence of obesity among American children and adolescents increased substantially over the past 30 years. A comparison of skinfold measurements and body mass index (BMI) from the National Health Examination Surveys (NHES) from 1963 to 1970 with NHES measurements from 1980 and 1990 revealed that one in five children and adolescents is overweight. Severe obesity has increased more quickly than even the increases of moderate over fatness.
The etiology of these changes is not obvious but may be considered multifactorial.
Eating more food as snacks and meals away from home may be a subtle factor for children and adults. These food portions tend to be larger and higher in calories and dietary fat than those eaten at home. Another factor may be the increase of sedentary lifestyles. Physical activity has decreased, with a related decline of fitness.
Although TV watching has not increased substantially over the years, children may be more sedentary than in the past because they play video and computer games and “surf” the Internet. Physical and behavioral environmental influences also affect the level of physical activity. If facilities are not available or not safe to use, activity is limited. Concerns over increasing numbers of latchkey children (grade-school children arriving home without adult supervision until the evening) focus on the use of food for emotional comfort and security. All of these factors impact the effect of genetics, which may predispose children toward heavier weights and should be considered as interventions are considered.
Clinical assessment of obesity consists of completing a health history including the pattern of weight gain, emotional health status, and physical activity patterns.
If BMI is greater than
As with adults, intervention regarding weight should only be initiated when the patient is motivated or is experiencing weight associative disorders. Conducting a 24-hour recall provides an opportunity to engage in a discussion of dietary intake patterns such as excessive or imbalanced intake of nonnutrient-dense foods such as sodas, sweets, and fast foods. (This type of discussion may be appropriate regardless of the child’s weight.) Physical examinations need to be sensitive to the child regarding his or her weight and body issues. If weight is excessive, the assessment can determine if weight causes physical symptoms such as sleep apnea.
Morbidly obese adolescents may require a more comprehensive physical examination and intervention approaches.
Treatment, if warranted, must include the family. The goal is to maintain the current weight of the child while growth continues. Children should not be “dieting,” but guidance can be provided to the child and caregivers as to healthier eating patterns.
Education about dietary patterns such as the Food Guide Pyramid and food choices to restructure dietary intake patterns may be sufficient and should be conducted by a dietitian who has the expertise to work with children and their families.
The goal of treatment should not be to reach an “ideal weight” but to develop and maintain a healthy lifestyle that includes acceptance of diverse body sizes.
Role of Nurses
Nurses support the goals of health promotion of obese children by being sensitive to the emotional, social, and physical dimensions associated with weight and body composition. As allies, nurses create an affirming medical environment for large children by awareness of their own behavior when conducting physical examinations, such as quietly recording weight rather than announcing weight aloud in a medical office or school setting. Pediatric offices should also have examining gowns large enough to adequately be used by larger pediatric patients.
Iron Deficiency Anemia
For children, poverty is a significant risk factor for iron deficiency anemia. Economically deprived children of inner cities are most at risk because of the dual risk of lead poisoning, which reduces the amount of iron absorbed by the body, and chronic hunger that limits the intake of adequate nutrients. Lead poisoning and iron deficiency each contribute to learning failure. Ability to learn is decreased because cognitive and motor abilities are altered and this limits the ability to explore, focus, and benefit from the education environment. Although poor Americans of any group are at risk, African American, Hispanic American, and Native American children are most likely to have inadequate intakes of iron.
Malnourished children may be developmentally delayed and unable to benefit from educational experiences. The effects of iron deficiency anemia may begin in childhood and carry through adolescence and into adulthood, limiting the productivity and potential accomplishments of individuals.
Although iron deficiency has been recognized as a public health issue for many years, it is still a concern. It is possible that federal government programs to increase nutrition status among poor Americans may actually work against decreasing iron deficiency.
For example, the U.S. Federal Commodity Food Program releases cheese and butter to the poor. Not only are these foods high in fat but they also are particularly poor sources of iron and may contribute to the continuing prevalence of iron deficiencies. Another contributing factor may be that in 1997, the USDA began to allow the School Lunch Program to substitute yogurt for meat/protein requirements.
For the general population, the effect on iron intake may be minimal, but for economically disadvantaged children, the amount of iron consumed through school lunch servings of meat, poultry, fish, and beans is significant. The effects of chronic poverty and malnutrition are so intertwined that simple nutritional intervention will not overcome the deficits of social deprivation.
Role of Nurses
Nurses, particularly school nurses, can educate teaching staff about the relationship between iron deficiency and learning ability. Children may be labeled as slow learners and “behavior problems” when iron deficiency may be the cause of learning difficulties.
Food Allergies and Food Intolerances
Food allergies and food intolerances pose nutritional and social challenges for children, their families, and caregivers. Although adults may also experience adverse responses to foods, infants and children are most commonly affected. About 6% to 8% of children and 0.5% to 2% of adults have documented food allergies.
Commonly affected individuals are those with asthma and hay fever.
Food Allergy
A food allergy is the overreaction of the immune system to a food protein or other large molecule that has been absorbed and interacts with the immune system that produces a response. The body produces antibodies to protect itself from the foreign substance, the protein allergen. The reaction causes a variety of physical symptoms that occur immediately (less than 2 hours), intermediately (2 to 24 hours), or delayed (over 24 hours).18 The most common food allergies experienced by children are peanuts, milk, eggs, and wheat. Seafood and peanuts are more common among older children and adults. Cross reactivity also occurs. For example, if a person is affected by a ragweed allergy, reaction to melons and bananas may occur.
Symptoms may include skin, respiratory, and gastrointestinal reactions.
Reactions may affect breathing ability if the upper airway becomes obstructed because of swelling. If the symptoms are treated as asthma, instead of a true food allergy, the misdiagnosis may trigger more serious physical responses and a continuation of symptoms because the offending food may continue to be consumed.
Reactions for a small number of individuals may be so severe as to be life threatening.
This type of reaction is called anaphylaxis and may occur immediately after eating the food substance. Peanuts, eggs, shellfish, and nuts may cause anaphylaxis in sensitive individuals. Symptoms may include hives, breathing difficulties, and unconsciousness. It requires immediate medical care or a plan of action in case inadvertent consumption of the offending food occurs. Caregivers, whether parents, school officials, family, or friends, must be aware of the potential reaction and the appropriate and immediate treatment for the anaphylaxis response.
Risk Factors.
Risk factors include heredity, gastrointestinal permeability, and environmental factors. Heredity is a risk factor because if parents have allergies, their children are most at risk. Gastrointestinal permeability affects the amount of the antigen inappropriately absorbed. Environmental factors can increase food allergic responses. Environmental factors include increased exposure to inhalant seasonal allergies such as pollen and cold weather and other environmental allergens of dust, mold, dust mites, smoke, and stress.
In contrast to a food allergy, food intolerance is an adverse reaction to a food that does not involve the immune system. The symptoms are triggered by a reaction of the body to a food. Pharmacologic properties of foods (e.g., tyramine in aged cheese, theobromine in chocolate), metabolic disorders (e.g., lactose intolerance), or idiosyncratic responses may cause the reaction.
Lactose intolerance is an example of a food intolerance. The lack of the enzyme lactase limits the digestion of lactose, leading to physical symptoms of bloating, flatulence, diarrhea, and nausea. The resulting symptoms can be similar to and mistaken as a food allergy. Treatment, though, is different than if a true allergy. For lactose intolerance, products are available that contain reduced lactose, or there are pills (e.g., Lactaid) that break down lactose, thus easing digestion. In contrast, if the symptoms are caused by a food allergy, the offending substance in milk (the milk proteins) are not affected by the reduction of lactose (a carbohydrate) and the immune system response and symptoms would still occur.
Diagnosis
Determination of whether a reaction is caused by a food allergy or by intolerance requires consultation with a healthcare provider specializing in allergies. Diagnosis involves a health history and physical examination, food and symptom diary, biochemical and immunologic testing, and a food elimination procedure.18 The health history records symptoms, including the reaction time from ingestion to symptoms, and a family allergy history, in addition to traditional information of health histories. The physical examination assesses weight and height patterns to determine whether potential malnutrition may be present because of the effects of the food allergies. Related allergenic symptoms such as eczema are noted. A food and symptom diary keeps track of amounts of food consumed, time and day of consumption, and any resulting symptoms. This information is valuable to begin to isolate potential food allergens. Biochemical testing such as a complete blood count rules out symptoms caused by conditions unrelated to food allergies. Immunologic testing through skin pricking of individual foods assists in identifying potential food allergens based on reactive immunologic adverse reactions, such as swelling and welts at the site of the skin prick.
A food elimination process consists of not eating foods suspected of being allergenic for 2 weeks to allow the person to become symptom-free. Guidance during this phase is crucial to ensure complete compliance. Adequate nutrition can be sustained by substitution of other foods to provide nutrients lost by the elimination of allergenic foods. A registered dietitian or qualified nutritionist should be consulted for appropriate elimination diets. To ensure the accuracy of the diagnosis, a food challenge is implemented. This consists of consuming the allergenic food and assessing the responsive symptoms. Severe reactions are possible. Consequently, food challenges should be conducted in an appropriate healthcare setting. Another protocol is to conduct a double-blind, placebo-controlled food challenge. Rechallenges may be conducted after several years to assess if the food allergy is still present.
Treatment
The only way to treat a food allergy is to avoid consumption of the food. Referral to a registered dietitian for nutrition counseling is important, and family and caregivers should be included in the nutrition counseling process. Nutrition counseling identifies alternative sources of nutrients to assure appropriate substitutions for the foods eliminated.
Nutrition counseling also assists in teaching how to use food labels to recognize the different terms of allergenic items. Valuable assistance is provided by organizations such as the Food Allergy Network, which provides a newsletter, informational Web site, and other educational supports. Planned nutrition counseling follow-up sessions should be considered to assess progress in complying with dietary recommendations.
Life Health Promotion: Adulthud.
The science of nutrition is dedicated to learning about foods that the human body requires at different stages of life in order to meet the nutritional needs for proper growth, as well as to maintain health and prevent disease. A baby is born with a very high requirement for energy and nutrient intake per unit of body weight to provide for rapid growth. The rate of growth is the highest during the first year and declines slowly after the age of two, with a corresponding decrease iutrient and energy requirements.
During puberty, however, nutritional requirements increase sharply until this period of fast growth is completed. Adulthood begins at about the age of fourteen or fifteen for girls, and eighteen or nineteen for boys.
An adult individual needs to balance energy intake with his or her level of physical activity to avoid storing excess body fat. Dietary practices and food choices are related to wellness and affect health, fitness, weight management, and the prevention of chronic diseases such as osteoporosis, cardiovascular diseases, cancer, and diabetes.
For adults (ages eighteen to forty-five or fifty), weight management is a key factor in achieving health and wellness. In order to remain healthy, adults must be aware of changes in their energy needs, based on their level of physical activity, and balance their energy intake accordingly.
As teenagers reach adulthood, the basal energy needs for maintaining the body’s physiological functions (basal metabolic rate, or BMR) stabilize, and so energy requirements also stabilize. BMR is defined as the energy required by the body to keep functioning. These functions include the pumping of blood by the heart, respiration, kidney function, and maintaining muscle tone and a constant body temperature, among others. BMR is directly related to the amount of lean body muscle mass, size, and gender. Physical activity, especially weight-training exercises, help increase and maintain lean body mass.
It is very important to reduce one’s energy intake at the onset of adulthood, and to make sure that all of one’s nutritional needs are met. This can be accomplished by making sure that an adequate amount of energy is consumed (this will vary by body weight, degree of physical fitness, and muscle vs. body fat), and that this amount of energy is adjusted to one’s level of physical activity. Foods that are chosen to provide the energy must be highly nutritious, containing high amounts of essential nutrients such as vitamins, minerals, and essential proteins.
It is usually at this age that young adults start gaining body fat and reducing their physical activity, resulting in an accumulation of fat in the abdominal areas. This is an ever-increasing risk factor in the population of the
At the onset of adulthood, energy requirements usually reach a plateau that will last until one’s mid-forties, after which they begin to decline, primarily because activity levels and lean muscle mass (amount of muscle vs. body fat), which represents the BMR, decrease. It is believed that the changes in body composition and reduced lean muscle mass occur at a rate of about 5 percent per decade, and energy requirements decrease accordingly. However, these changes in body composition and decreased energy requirements can be prevented by maintaining regular physical activity, including resistance training, which helps maintain lean muscle mass and prevent deposition of excess body fat.
The basal metabolic rate—the number of calories a person’s body uses while at rest—generally decreases with age. Good health requires adults to adapt their diets to the body’s changing needs by eating low-fat and nutrient-rich foods.
By preventing normal age-related decline in lean muscle mass, one can prevent obesity and prolong one’s physiological age. The result is that a person is less vulnerable to degenerative diseases, such as cardiovascular diseases, cancer, and diabetes, and can usually perform at a higher level than his or her chronological age would otherwise allow.
Older adults who are not physically active or who have poor nutritional practices will have a decline in BMR, a change in body composition, an increasing percentage of body fat, and a decrease in lean body muscle mass. In addition, they will show the signs of aging and will be more likely to develop degenerative diseases.
Many older adults need to take medications to control the advance of diabetes, hypertension, and cardiovascular disease. Medications can interfere with proper nutrition, however, as they affect appetite, the digestion and absorption of nutrients, and normal function of the digestive system.
As women age, they may develop osteoporosis if they have not built up strong bones by eating foods high in calcium and adequate vitamin D. Women start losing calcium from bones during and after the onset of menopause at the rate of 1 percent per year for about five years, after which the rate of calcium loss is reduced until about age seventy-five or eighty. Therefore, it is important for women to eat foods high in calcium up to the age of thirty-five. The recommended daily intake of calcium is 1,200 milligrams. This requirement can be met by consuming four servings of dairy products and two servings of green vegetables each day. It is well established that calcium from foods is much better absorbed than calcium from supplements. It is beneficial, therefore, to choose foods with a high calcium content, such as low-fat or skim dairy products. This regimen builds a bone density high enough so that, at menopause, losing approximately 5 percent of bone density in five years does not place a woman in the “fracture zone,” where bones can break as a result of
Whether you are 50 or 85, active or homebound, your food choices will affect your overall health in the years ahead. The risk for certain diseases associated with aging such as heart disease, osteoporosis and diabetes can be reduced with a lifestyle that includes healthy eating. Good nutrition also helps in the treatment and recovery from illness. While healthy living can’t turn back the clock, it can help you feel good longer.
Eating healthfully means consuming a variety of good foods each day. Food provides the energy, protein, vitamins, minerals, fiber and water you need for good health. For one reason or another your body may not be getting the right amounts of these nutrients.
There are several factors that indicate an increased risk for poor nutrition. If you have three or more of the risk factors listed below consult with a physician or registered dietitian:
- ill health
- poor eating habits
- unexpected weight gain or loss
- taking medications
- poor dental health
- economic hardship
- loneliness and lack of social contacts
- the inability to care for yourself
Nutrition Facts
Older adults need the same nutrients as younger people, but in differing amounts. As you get older, the number of calories needed is usually less than when you were younger. This is because basic body processes require less energy when there is a decline in physical activity and loss of muscles. However, contrary to popular belief, basic nutrient needs do not decrease with age. In fact, some nutrients are needed in increased amounts. The challenge is to develop an eating plan that supplies plenty of nutrients but not too many calories.
This can be done by choosing nutritious foods that are low in fat and high in fiber like whole grain breads and cereals, fruits and vegetables. Also be sure to include moderate amounts of low-fat dairy products and protein foods like meat, poultry, fish, beans and eggs. Sweets and other foods high in sugar, fat and calories can be enjoyed from time to time but the key is to eat them sparingly.
The Food Guide Pyramid is a great guide for your daily food choices. Calorie needs vary depending on age and activity level but for many older adults 1600 calories each day will meet energy needs. Chosen carefully those 1600 calories can supply a wealth of nutrients. The recommended number of daily servings from each group in the Food Guide Pyramid, with a few additions of fats, oils and sweets, will easily add up to 1600 healthful calories.
Calcium is important at any age and may need special emphasis as you grow older. Calcium is a mineral that builds strong bones and helps prevent osteoporosis. Many older adults don’t eat enough calcium rich foods and the aging body is less efficient in absorbing calcium from food. In addition, many adults don’t get enough weight bearing exercise like walking to help keep bones strong.
It is not too late to consume more calcium and reduce the risk of bone fractures. Eat at least 2-3 servings of calcium rich foods everyday. Low-fat milk, yogurt and cheese are good choices. Some dark green, leafy vegetables, canned salmon with edible bones, tofu made with calcium sulfate, and calcium fortified soy milk can add a significant amount of calcium to your diet. In addition, do some weight bearing exercise like walking for a total of 30 minutes each day.
The National Institutes of Health advise adults over 65 to consume 1500 mg of calcium daily. This amount may be difficult to achieve through food alone so for some people a calcium supplement is a wise choice. If you do take a supplement, take it between meals. Calcium can hinder the absorption of iron from other foods.
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One Serving Equals |
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Grain |
Milk, Yogurt, and Cheese |
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1 slice of gread |
1 cup milk or yogurt |
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Fruits and Vegetables |
Meat, Poultry, fish, Dry Beans, Eggs and Nuts |
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1 cup raw, leafy vegetables 1/2 cup cooked, chopped or canned 3/4 cup joice 1 medium |
1- |
Can Food Do It ALL?
Yes, food can provide an adequate diet and the pleasures of eating too. But for those who are unable or unwilling to eat a healthy diet a multivitamin and mineral supplement is a good way to get all the needed vitamins and minerals. The guideline is to get enough without getting too much. Look for a supplement that provides about 100% of the RDA. Physicians regularly prescribe supplements for certain health conditions. It is not a good idea to take mega-doses without first discussing it with your physician. Beware of supplements that claim to be magic or promise miracle cures. Taking unproven remedies in place of well-proven treatments could make your health worse in the long run.
Vitamin D protects against bone disease by helping deposit calcium into bones. Known as the sunshine vitamin, it is made within the skin by exposure to the sun’s ultraviolet rays. Only 20 to 30 minutes of sunlight on the hands or face two to three times per week will provide enough vitamin D. However, dark skinned people do not make vitamin D from sunlight so they must get it from food sources. Food sources of vitamin D include fortified milk and cereals. Look for it on food labels.
Vitamin C helps your body absorb iron from plant sources of food. Most people who follow the guidelines of the Food Guide Pyramid consume enough vitamin C. Poor eating habits or smoking can contribute to low levels of vitamin C. A lack of vitamin C can cause bleeding gums, delay wound healing and contribute to low levels of iron. The most effective way to increase vitamin C is to eat citrus fruits, melons, tomatoes, green peppers and berries.
Sodium is found naturally in foods such as milk, seafood and eggs. Processed foods such as tomato juice, frozen dinners, canned soups, canned fruits and canned vegetables are high in added sodium. People with high blood pressure and certain types of heart disease may be advised by their physicians to reduce the amount of sodium in their diets. For healthy adults, the American Heart Association recommends not more than three grams (3000 mg) of sodium each day. One and a half teaspoons of salt is equal to 3000 mg of sodium, so go lightly with the salt shaker.
Special Considerations
The ability to smell and taste may decline gradually with age. When the sense of smell becomes dulled, it affects the sense of taste and makes food less appetizing. Also, some medications may leave a bitter taste, which affects saliva, giving foods a bad flavor. Smoking reduces the ability to enjoy flavors too. Poor eating habits can result when food just doesn’t taste as good as it used to.
To compensate for the loss of smell and taste, create meals that appeal to all the senses. Intensify the taste, smell, sight, sound and feel of foods. Perk up flavors with herbs, spices and lemon juice rather than relying solely on salt or sugar. Choose foods that look good and have a variety of textures and temperatures. Try new ideas. Use garlic and seasoning on foods, add a new texture like crushing crackers in soup, or change the temperature like serving applesauce warm with cinnamon.
Dry mouth is another problem faced by many older adults. When it feels like your mouth is filled with cotton balls and your lips are parched and cracked, food just doesn’t taste good. It can be difficult to chew and swallow because of a lack of saliva. Dry mouth is a potential side effect of many medications such as drugs to lower blood pressure or treat depression. It may also be a symptom of cancer or kidney failure.
To relieve dry mouth discomfort, watch out for spicy foods that irritate the lips and tongue. Eat soft foods that have been moistened with sauces or gravies. Try sucking on hard candies or popsicles and drink plenty of fluids. A room humidifier may help by moistening the air. It will also help to breathe through your nose–not your mouth.
Tooth loss or mouth pain can be an obstacle to good eating. Generally, people who wear poorly fitting dentures chew 75% to 85% less efficiently than those with natural teeth. Dentures should be adjusted for a proper fit. Softer foods are easier to chew. Drinking plenty of water or other fluids with meals may make swallowing easier. Good dental care (brushing, flossing, regular check-ups) will help keep teeth and gums healthy.
Many older adults say they just aren’t hungry. There are many factors that influence appetite including digestive problems, certain medications, depression or loneliness. To encourage eating and appetite, keep portions small, allow plenty of time to dine, eat smaller meals more often, prepare attractive meals, play dinner music, eat meals with friends, and increase physical activity where possible. Consult a physician if the lack of appetite results in unwanted weight loss.
Constipation can be a chronic problem for many older adults. It can be caused by not getting enough fiber or fluids and by being physically inactive. To stay regular and avoid the strain of constipation engage in physical activity, drink plenty of fluids and eat fiber rich foods such as whole grain breads and cereals, legumes, vegetables and fruit. Fiber gives bulk to stools and fluids help keep stools softer making them easier to eliminate.
Some older adults have trouble digesting milk, even if it wasn’t a problem in their younger years. The small intestine may no longer be producing the enzyme lactase which breaks down the natural sugar, called lactose, in milk. When the lactase enzyme is missing you may experience bloating, abdominal cramps and diarrhea. Tolerance to lactose is variable. Try eating smaller amounts of these foods, eating them during a meal instead of alone or having them less often (perhaps every other day). Lactose-reduced and -free products are now available. Look for them in your supermarket. Also, the lactase enzyme is available in tablets or drops that can be added to milk before drinking. Follow the specific directions found on the packages.
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Quick and Easy Eating |
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Here are some suggestions if you don’t have the time or inclination to cook good meals:
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Medications and older age often go together. Medications improve health and quality of life but some can profoundly affect nutritional needs. Be sure to consult with the physician or pharmacist as to specific instructions concerning food-drug interactions and directions on when and how to take medications.
Part of the pleasure of eating is in socializing with others. Many older adults who live alone may find mealtimes boring or depressing. Put some fun back into eating by getting together with friends for weekly or monthly potluck dinners. Look for a senior center in your community. This is a great way to meet old and new friends and many have programs that offer a midday meal on weekdays. Take advantage of early bird specials or senior discounts at restaurants and don’t hesitate to take home a ‘doggie bag’. Invite a friend to lunch at your home. Join a community service club or organization. Many of these groups plan social activities which often include getting together for meals. When home alone, make eating a special event with candles, tablecloth, music and something delicious to eat.
Look to local agencies for help for older adults who find it hard to cook their own meals or get out of the house. Meals-On-Wheels programs provide food for people who are homebound. Home health care organizations can provide aides who will shop and prepare meals for older disabled adults. Some local churches or community groups have volunteers who will help older adults with shopping and food preparation.
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A Day of Good Nutrition Sample Menu |
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Breakfast |
Bread |
Vegetables |
Fruit |
Milk |
Meat |
Fluids |
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1 |
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1 cup 1% milk |
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1 |
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1 |
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1 banana |
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1 |
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coffee or tea |
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1 |
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Mid Morning |
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1 |
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3/4 |
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1/2 raisin bagel |
1 |
|
|
|
|
|
|
Lunch |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sandwich |
|
|
|
|
|
|
|
|
|
|
|
|
1 |
|
|
on whole wheat |
2 |
|
|
|
|
|
|
lettuce and tomato |
|
1 |
|
|
|
|
|
1/4 cantaloupe |
|
|
1 |
|
|
|
|
2 graham crackers |
1 |
|
|
|
|
|
|
iced tea |
|
|
|
|
|
1 |
|
Mid Afternoon |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1 |
|
|
|
1 glass water |
|
|
|
|
|
1 |
|
Dinner |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1 |
|
|
1/2 cup rice |
1 |
|
|
|
|
|
|
1/2 cup cooked carrots |
|
1 |
|
|
|
|
|
1/2 cup cranberry sauce |
|
|
1 |
|
|
|
|
1/2 cup vanilla pudding (low fat milk) |
|
|
|
1 |
|
|
|
1 glass water |
|
|
|
|
|
1 |
|
cup of tea |
|
|
|
|
|
1 |
|
|
||||||
|
Totals |
6 |
3 |
3 |
3 |
2 |
6-7 |
Prevalence of Obesity Among Adults
Obesity among adults is defined using a measure of weight in relation to height known as the Body Mass Index (BMI). The BMI is used to determine whether an adult, male or female, falls into a broad range considered to be underweight, healthy weight, overweight, or obese.
|
BMI Category |
||
|
below 18.5 |
– |
Underweight |
|
18.5-24.9 |
– |
Healthy Weight |
|
25-29.9 |
– |
Overweight |
|
over 30 |
– |
Obese |
The prevalence of obesity among adults in
*Body Mass Index ( BMI ) >= 30 obese.
Source:
Overweight, a predecessor to obesity, has also increased in
*Body Mass Index ( BMI ) 25-29.9 overweight and >= 30 obese.
Source:
Overweight and obesity varies by gender. More males are overweight compared to females, 44 percent versus 29 percent in 2005. Males lead females in the combined overweight and obesity rates as well, 71 percent for males and 52 percent for females in 2005. However, there was an alarming increase in obesity among females in
Source:
Source:
While the obesity rate has risen among
Prevalence of Diabetes Among Adults
Diabetes among adults is defined as having been told by a health professional that you have diabetes. Slightly more than one out of twenty (6%) adults in
Source:
