NCM 105

Nutrition and Diet Therapy

PRELIMINARY EXAMINATION NOTES

Lecture 1
Basic Concepts in Nutrition and Diet Therapy

Defining Food, Nutrition, and other Related Terms

Digestion - The process of breaking down food into substances that aid the body in its
different functions.

Food - Any substance that people eat and drink to maintain life and growth.

Nutrients - Substances obtained from food and used by the body for energy, building
and repairing tissues, and regulating body processes.

Nutrition - Study of how the body uses food.

Nutritional Status - Physiological state of an individual as determined by the kinds and amount
of food consumed and by the ability of the body to use them.

Malnutrition - A condition of the body caused by sustained deficiency, excess, or

imbalance in one or more nutrients.

Classification of Nutrients

Food is eaten and digested in the body to allow the absorption of energy and nutrients.

There are two different types of nutrients:

- macronutrients;
- micronutrients.
Macronutrients

There are three macronutrients that are essential for health. These are:

- Carbohydrate;

The two types of carbohydrate that provide dietary energy are starch and sugars. Dietary
fibre is also a type of carbohydrate which is not digested to provide energy. Starchy
carbohydrate is an important source of energy. 1 gram of carbohydrate provides 4kcal.

All types of carbohydrate are compounds of carbon, hydrogen and oxygen (CHO). They
can be classified in many different ways. One common way is according to their structure.

Sugars

Sugars come from a variety of foods. Some are within the cellular structure of the food,
e.g. in fruit or vegetables. Other sugars are not bound into the cellular structure of the
food, e.g. in milk or honey.

Free sugars include all sugars added to foods plus sugars naturally present in honey,
syrups and unsweetened fruit juice. The term does not include lactose (the sugar in milk)
when naturally present in milk and dairy products and the sugars contained within the
cellular structure of foods (e.g. fruit and vegetables).

The recommendations state that less than 5% of total energy intake should come from
free sugars.

Simple Carbohydrates

Simple carbohydrates are the different forms of sugar, which are easy for the body to
process. These sugars are monosaccharides such as fructose and glucose (found in fruits
and vegetables) and galactose (found in milk and dairy products) and disaccharides such
as lactose (glucose plus galactose), and sucrose (glucose plus fructose, refined and
purified to produce table sugar) and maltose (2 units of glucose).

The most important to the body is glucose – the form of the sugar that goes directly to
the bloodstream and provides quick energy. All other sugars must be changed into
glucose by the body before the cells can use them. The cells use glucose as their primary
source of energy. Glucose that is not needed immediately is converted by body to
glycogen, a form of starch stored in the muscles and liver, or it is converted to and stored
as body fat.
 Complex Carbohydrates

Starches are complex carbohydrates that are made up of many units of glucose or other
sugars, which form long chains. These chains must be broken down by the body into single
units of glucose before they can be used. Starches take longer than sugars to be broken
down into glucose. Starches provide energy to the body over longer periods than do
simple sugars. Breads, cereals, pasta, and potatoes contain starch.

Dietary Fiber is another complex carbohydrate, which comes from non-digestible part of
plants. There two types of dietary fiber: soluble and insoluble. Soluble fiber combines with
waste and other substances to assist in their removal from the body. (Found in: oat bran,
beans, apples, carrots, and other vegetables). Insoluble fiber absorbs water and helps to
provide needed bulk to the diet. (Found in: whole grains and the skins and seeds of fruits
and vegetables).

- Protein;

Protein is essential for growth and repair and keeping cells healthy. Protein also provides
energy: 1 gram of protein provides 4 kcal.

Protein is made up of building blocks called amino acids. Different foods contain different
amounts and different combinations of amino acids (CHON). Protein from animal sources
(e.g. meat, fish, eggs and dairy products) contains the full range of essential amino acids
needed by the body. Protein from plant sources (e.g. pulses and cereals) typically contain
fewer essential amino acids.

- Fat.

Fat provides fat-soluble vitamins A, D, E and K, and is necessary for their absorption. It is
also important for essential fatty acids the body cannot make. Fat provides a concentrated
source of energy: 1 gram of fat provides 9 kcal of energy. Foods that contain a lot of fat
provide a lot of energy.

Fat is made up of different types of fatty acids and glycerol. The structure of the fatty acids
determines:
• their effect on our health;
• their characteristics, e.g. melting point.

Depending on their chemical structure, fatty acids are usually classified as:
• saturated;
• monounsaturated;
• polyunsaturated.
 Types of Fat

Saturated fats are usually solid at room temperature. They contain maximum number of
hydrogen atoms. Tropical oils, butter, and animal fats tend to be high in saturated fats.
A diet high in saturated fats can lead to an increased chance of heart and blood vessel
disease, obesity, and some types of cancer.

Unsaturated fats are those fats that are liquid at room temperature. Olive oil and peanut
oil are called monounsaturated fats because they lack one pair of hydrogen atoms. Fish
oils and most vegetables oils, such as corn, soybean, and sunflower oils, are called
polyunsaturated fats because they lack two or more pairs of hydrogen atoms.

Cholesterol

Eating foods high in fats, especially saturated fats may increase the level of cholesterol, a
waxy, fat-like substance produced by body.

Cholesterol is part of cell membranes and nerve tissues. It is used by body to form vitamin
D and other hormones. It is found only in foods that come from animals, such as butter,
eggs, and meats. It is not an essential nutrient because the body produces cholesterol in
liver.

As cholesterol levels in the body increase, the risk of heart and artery diseases increase.
Some of the cholesterol tends to be deposited on the walls of the arteries, thereby
reducing the flow of blood to the cells supplied by those arteries.

Two Forms of Cholesterol

Cholesterol is transported in the blood in two forms. LDL is the “bad” form that tends to
deposit cholesterol on the walls of the blood vessels. HDL is the “good” form that removes
cholesterol from the cells and brings it back to the liver and intestines to be recycled or
excreted. Exercise has been proven to raise HDL, low-fat diets lower LDL.

Micronutrients

There are two types of micronutrients:

- vitamins;
- minerals.

Vitamins and minerals are needed in much smaller amounts than macronutrients. Their amounts
are measured in milligrams (mg) and micrograms (μg).
(1mg = 0.001g)
(1μg = 0.001mg).
Vitamins

There are two groups of vitamins:

• fat-soluble vitamins, which can be stored in the body, e.g. vitamins A and D.

• water-soluble vitamins, which cannot be stored in the body and are therefore required daily,
e.g. B vitamins and vitamin C.

The B vitamins

There are many different B vitamins and each has a specific function in the body. These include:
- vitamin B1 (Thiamin);
- vitamin B2 (Riboflavin);
- vitamin B3 (Niacin);
- vitamin B6 (Pyridoxine);
- vitamin B12 (Cobalamin);
- Vitamin B9 (folate/folic acid).

Vitamin C

Vitamin C is needed to make collagen. This is required for the structure and function of skin,
cartilage and bones. It is an important nutrient for healing cuts and wounds and can also help
with the absorption of iron.

Minerals

Minerals are inorganic substances required by the body in small amounts for a variety of different
functions. The body requires different amounts of each mineral.
People have different requirements, according to their:
- age;
- gender;
- physiological state (e.g. pregnancy).

Calcium

The body contains more calcium than any other mineral. It is essential for a number of important
functions such as the maintenance of bones and teeth, blood clotting and normal muscle
function. Good sources are milk, cheese and other dairy products.

Iron

Iron is essential for the formation of haemoglobin in red blood cells. Red blood cells carry oxygen
and transport it around the body. Iron is also required for normal metabolism and removing
waste substances from the body.

Did you know? There are two types of iron; one from animals sources (e.g. liver and red meat)
and the other from plant sources (e.g. pulses, dark green leafy vegetables).

Sodium

Sodium is found in all cells and body fluids. It is needed for regulating the amount of water and
other substances in the body. Sodium is a component of table salt, known as sodium chloride
(NaCl).

Sodium intakes in the Philippines are considered to be too high. It is recommended that adults
and children 11 years and over not to have more than 6g of salt per day. Young children should
eat less. High sodium intake is considered to be one of the risk factors for high blood pressure.

Water

“The Forgotten Nutrient”

Water is found in every cell, in the spaces around the cells, in the fluid tissues of the body, and in
body cavities Water carries dissolved nutrients throughout our body and assists in all its functions
such as: digesting foods, removing wastes, regulating temperature, and cushioning sensitive
parts of our body.

Each day we lose two to three quarts of water and if this water is not replaced the body can
dehydrate. When minerals are dissolved, they break apart into ions. The ions formed in body
fluids are called electrolytes. These ions play a central role in water balance in the body.
Nutritional Guidelines for Filipinos

1. Eat a variety of foods everyday

2. Breastfeed infants exclusively from birth to six months, and then, give appropriate foods
while continuing breastfeeding.
3. Maintain your children’s normal growth through proper diet and monitor their growth
regularly.
4. Consume fish, lean meat, poultry, or dried beans.
5. Eat more vegetables, fruits, and root crops.
6. Eat foods cooked in edible/cooking oil daily.
7. Consume milk, milk products, and other calcium-rich foods such as small fish and dark
green leafy vegetables everyday.
8. Use iodized salt, but avoid excessive intake of salty foods.
9. Eat clean and safe foods.
10. For a healthy lifestyle and good nutrition, exercise regularly, do not smoke and avoid
drinking alcoholic beverages.

Daily Nutritional Guide Pyramid for Filipinos

A dietary guide that teaches the principle of eating a variety of foods every day at the right
amounts.

ü Composed of six food groups

ü DNGP is based on the Filipino dietary pattern (rice + viand or “ulam”, and fruits)
ü DNGP also shows the importance of drinking water, exercise or physical activity, and
personal and environmental hygiene.
Farm to Table Food Path

ü Families may have different food path.

ü If one or more of the paths are blocked, they can contribute to food insecurity and
malnutrition.

Food Security

All people, at all times, have physical, social, and economic access to sufficient, safe and
nutritious food which meet their dietary needs and food preference for an active and healthy
life.

Food and Nutrition Security

Achieved if adequate food is available and accessible to, and satisfactorily used and utilized by all
individuals at all times to live a healthy and active life.

Forms of Malnutrition

1. Undernutrition

a. Underweight - A condition when children weigh less than expected for their age and
gender; May indicate stunting or wasting or both (underweight-for-age)
b. Stunting - The child’s height is less than expected for their age and gender.
(underheight-for-age)
c. Wasting - The child’s weight is less than expected for their height and gender.
(underweight-for-height)
d. Marasmus – severe form of non-edematous malnutrition
e. Kwashiorkor – severe form of edematous malnutrition
 f. CED – Chronic Energy Malnutrition results from a long standing intake of a diet that
is inadequate
in energy to sustain optimal growth and physical activity
g. GAM – Global Acute Malnutrition is the term used to include all malnourished
children whether they have moderate or severe wasting or edema or some
combination of this conditions

2. Overnutrition
a. Overweight - Weighing too much for one’s length or height.
b. Obesity - A condition of being severely overweight.

3. Specific Deficiency
a. VADD – Vitamin A Deficiency Disorder is the term used to cover all physiological
disturbances caused by low Vitamin A status, including clinical signs and symptoms.
Occurs when people: 1) Do not consume enough Vitamin A-rich foods; 2) Do not
receive Vitamin A supplements on a regular basis; and c) Have frequent illnesses and
are undernourished.
b. IDA – Iron Deficiency Anemia is characterized by a decrease in the concentration of
hemoglobin (Hg) in the blood. Usually results from: 1) Low levels of iron and low iron
bioavailability in the diet; 2) Deficiencies in nutrients linked with iron absorption and
metabolism (Vit C); 3) Presence of hookworm, schistosomiasis, malaria, and other
pathological blood losses e.g. hemorrhoids; or 4) Repeated pregnancies and excessive
bleeding
c. IDD – Iodine Deficiency Disorder refers to all of the ill effects of iodine deficiency in a
population. It is determined by measuring the amount of iodine in the urine
(urinary iodine excretion or UIE) and by detecting the presence of goiter.
Lecture 2
Nutrition Across the Lifespan: Pregnancy, Infancy and Childhood Years

Principles of Human Nutrition

Every field of science is governed by a set of principles that provides the foundation for growth
in knowledge. These principles change little with time. Knowledge of the principles of nutrition
will serve as a springboard to greater understanding of the nutrition and health relationships
explored in the chapters to come.

Principle 1 – Food is a basic need of humans.

Principle 2 – Foods provide energy (calories), nutrients and other substances needed for
growth and development.
Principle 3 – Health problems related to nutrition originate within cells.
Principle 4 – Poor nutrition can result from both inadequate and excessive levels of nutrient
intake.
Principle 5 – Humans have adaptive mechanisms for managing fluctuations in food intake.
Principle 6 – Malnutrition can result from poor diets and from disease states, genetic factors,
or combinations of these causes.
Principle 7 – Some groups of people are at higher risk of becoming inadequately nourished than
others.
Principle 8 – Poor nutrition can influence the development of certain chronic diseases.
Principle 9 – Adequacy, variety, and balance are key characteristics of healthy dietary pattern.
Principle 10 – There are no “good” or “bad” foods.
Nutritional needs should be met at every stage of the life cycle because nutritional status at one
stage influences health status in the next ones. Lack of adequate nutrition during pregnancy, for
example, can program gene functions for life in ways that set the stage for lifelong metabolic
changes that increase the risk of chronic-disease development.

Disease prevention and health promotion, rather than repair of health problems, requires a focus
on meeting nutritional and other health needs of individuals during every stage of the life cycle.

NUTRITION DURING PREGNANCY

Periconceptional Period

The time around conception is considered the periconceptional period. It represents a critical
period of time when nutritional and other exposures can impact conception, pregnancy
maintenance, and the growth, development, and future health of the offspring.

Folate status prior to conception is an important concern because inadequate folate very early
in pregnancy is related to the development of approximately 50 percent of cases of neural tube
defects (NTDs), such as spina bifida. NTDs develop between the third and fourth week after
conception—or before many women even know they are pregnant, and well before prenatal care
generally begins.

Folate is an essential nutrient required for DNA replication and as a component of enzymatic
reactions involved in amino acid synthesis and vitamin metabolism.

Pregnancy (Gestation)

Is the period when the fertilized ovum implants itself in the uterus, undergoes differentiation,
and grows until it can support extra-uterine life. Human Pregnancy lasts for a period of 266 to
280 days (37-40 weeks).
Maternal Physiology

Conception triggers thousands of complex and sequenced biological changes that transform two
united cells into a member of the next generation of human beings. The rapidity with which
structures and functions develop in mother and fetus and the time-critical nature of energy and
nutrient needs make maternal nutritional status a key element of successful reproduction.

Weight Gain during Pregnancy

Weight gain during pregnancy is an important consideration because newborn weight and health
status tend to increase with adequate weight gain. Birthweights of infants born to women with
weight gains of 15 lbs. (7 kg.) for example, average 3100 grams (6 lb 14 oz). This weight is about
500 grams less than the average birthweight of 3600 grams (8 lb) in women gaining 30 pounds
(13.6 kg).

Maternal Weight Implications

1. Underweight
a. High risk of having low-birth weight infants
b. Higher rates of pre-term deaths and infant deaths
 2. Overweight and Obese
a. High risk of complications like hypertension, gestational diabetes, and postpartum
infections
b. Complications of labor and delivery
c. Increased likelihood of a difficult labor and delivery, birth trauma, and cesarean
section for large babies
d. Doubled risk of neural tube defects

Calorie Allowances

Energy requirements during pregnancy increase mainly due to protein and fat tissue synthesis,
and the energy cost of maintaining an expanding amount of metabolically active tissues. On the
average, an increase of 500 calories during the second half of pregnancy is recommended. As for
adults, approximately 45–65 percent of total caloric intake during pregnancy should come from
carbohydrates.

Protein Allowances

The FAO/WHO recommends an additional 9 g of protein per day for the latter part of pregnancy.
For a Filipino pregnant woman, this is equivalent to 68 g/day. For an adolescent pregnant
woman, it is equivalent to 73 g/day. Physiological adaptations in protein metabolism during
pregnancy shift in the direction of meeting maternal and fetal needs for protein. Consequently,
less protein is used for energy and more is used for protein synthesis.

Two-thirds of proteins should be of animal origin of the highest biologic value such as meat, milk,
eggs, cheese, poultry, and fish.

Fat Allowances

It is estimated that pregnant women consume 33 percent of total calories on average from fat.
Fat consumed in foods is used as an energy source for fetal growth and development and serves
as a source of fat-soluble vitamins. Fat also provides essential fatty acids that are specifically
required for components of fetal growth and development. It is recommended that pregnant
women consume 13 grams of linoleic acid (an essential fatty acid) daily, and 1.4 grams of the
other essential fatty acid, alpha-linolenic acid.

Vitamin and Mineral Allowances

Folate
Folic acid taken in a supplement without food provides twice the dietary folate equivalents as
does an equivalent amount of folate from food. It is recommended that women consume 600
mcg DFE of folate per day during pregnancy and include 400 mcg folic acid from fortified foods
or supplements. The remaining 200 mcg DFE should be obtained from vegetables and fruits.
These nutrient-dense foods provide an average of 40 mcg of folate per serving.
Vitamin A
It is a key nutrient in pregnancy because it plays important roles in reactions involved in cell
differentiation. Deficiency of this vitamin is rare in pregnant women in industrialized countries,
but it is a major problem in many developing nations. Vitamin A deficiency that occurs early in
pregnancy can produce malformations of the fetal lungs, urinary tract, and heart.

Vitamin D
It supports fetal growth, the addition of calcium to bone, and tooth and enamel formation. Lack
of a sufficient supply of vitamin D during pregnancy compromises fetal as well as childhood bone
development. Lack of maternal Vitamin D readily compromises fetal Vitamin D status. Infants
born to women with vitamin D deficiency tend to be smaller than average, more likely to have
low blood calcium levels (hypocalcaemia) at birth, and more likely to have poorly calcified
bones and abnormal enamel. They are also more likely to develop dental caries in childhood.

Calcium
It is primarily needed in pregnancy for fetal skeletal mineralization and maintenance of maternal
bone health. Approximately 30 grams of calcium (a little over an ounce) is transferred from the
mother to the fetus during pregnancy. Fetal demand for calcium peaks in the third trimester
when fetal bones are mineralizing at a high rate. The additional requirement for calcium in the
last quarter of pregnancy is approximately 300 mg per day and is partly obtained by increased
absorption and by release of calcium from bone.

Iron
Iron status is a leading topic of discussion in prenatal nutrition because the need for iron
increases substantially; women require about 1000 mg (1 g) of additional iron for pregnancy:

◗ 300 mg is used by the fetus and placenta.

◗ 250 mg is lost at delivery.
◗ 450 mg is used to increase red blood cell mass.

Maternal iron stores get a boost after delivery when iron liberated during the breakdown of
surplus red blood cells is recycled.

Iodine
Iodine is required in pregnancy by the mother and fetus for thyroid function and energy
production, and for fetal brain development. Deficiency of iodine early in pregnancy can lead to
hypothyroidism in the offspring. The recommended form of iodine for supplements is
potassium iodide (which contains 76 percent iodine). Usual iodine intake should not exceed
1100 mcg daily during pregnancy.
Sodium
It plays a critical role in maintaining the body’s water balance. Requirements for it increase
markedly during pregnancy due to plasma volume expansion. But the need for increased
amounts of sodium in pregnancy hasn’t always been appreciated. Sodium restriction is not
indicated in normal pregnancy or for the control of edema or high blood pressure that develops
in pregnancy. Women should be advised to consume salt “to taste” unless contradicted by a
medical condition related to salt intake.

Complications of Pregnancy

Some of the physiological changes that occur in pregnancy are accompanied by side effects that
can dull the bliss of expecting a child by making women feel physically miserable. Common
ailments of pregnancy, such as nausea and vomiting, heartburn, and constipation, are generally
more amenable to prevention than to treatment, but often can be relieved through dietary
measures.

Hyperemesis Gravidarum
Hyperemesis is characterized by severe nausea and vomiting that last throughout much of
pregnancy. It can be debilitating. In addition to the mother feeling very sick, frequent vomiting
can lead to weight loss, electrolyte imbalances, and dehydration.

Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy are a worldwide, leading cause of maternal mortality. They
affect 5–10 percent of pregnancies and contribute significantly to stillbirths, fetal and newborn
deaths, and other adverse outcomes of pregnancy. Four types of hypertensive disorders in
pregnancy have been identified.

Gestational Diabetes
Gestational diabetes accounts for 88 percent of all cases of diabetes in pregnancy and is similar
in many ways to type 2 diabetes. Women who develop gestational diabetes tend to enter
pregnancy with insulin resistance, or a predisposition to insulin resistance, and impaired insulin
production, which is expressed due to physiological changes that occur during pregnancy.

Eating Disorders
Eating disorders represent relatively rare conditions in pregnancy because many women with
such disorders are sub-fertile or infertile. Such disorders can have far-reaching effects on both
mother and fetus, however, when they do occur. The eating disorder most commonly observed
among pregnant women is bulimia nervosa, a condition marked by both severe food restriction
and bingeing and purging. Pica is a temporary condition wherein pregnant women had the
tendencies to eat non-food items.

Fetal Alcohol Spectrum Disorders

Alcohol consumed by a woman easily crosses the placenta to the fetus. Because the fetus has yet
to fully develop enzymes that break it down, alcohol lingers in the fetal circulation. This situation,
combined with the fact that the fetus is smaller and has far less blood than the mother does,
increases the harmful effects of alcohol on the fetus as compared to the mother.

NUTRITION DURING LACTATION

The preparation for assuring an adequate supply of good quality breastmilk must begin at the
onset of pregnancy. Most of the dietary essentials are increased over and above the
requirements during pregnancy to meet the demands of milk production, namely calories,
proteins, calcium, Vitamin A, thiamin, riboflavin, niacin, and ascorbic acid.

Calorie Allowances

The actual mechanism involved in the production of the milk does not demand a great
expenditure of energy. The extra energy required for lactation depends on the amount of milk
produced. The FNRI recommends an increase of 1,000 calories above the normal requirement
for an average production of 850 mL of milk, with an energy value of about 600 calories.

Importance of Breastmilk

Mother’s milk is the best food for the baby. It is easily digested, economical, has the right
temperature, and is free from harmful bacteria.

A mother who wants to breastfeed her baby should follow the basic food groups in meal
planning. Too much fried foods, pickles, and highly-seasoned foods and stimulants such as drugs,
nicotine, caffeine, theobromine, morphine, and alcohol should be avoided.
Colostrum

For the first 3 to 4 days, the milk contains a substance called colostrum. Colostrum has high
protein content, acts as a laxative, and contains antibodies which help resist infection. It should
be given to all newborn infants.

Benefits of Breastmilk for the Infant

• Provides superior nutrition for optimum growth.

• Provides adequate water for hydration.
• Protects against infection and allergies.
• Promotes bonding and development.

Benefits of Breastmilk for the Mother

• Protects mother’s health

• helps reduces risk of uterine bleeding and helps the uterus to return to its
previous size
• reduces risk of breast and
ovarian cancer
• Helps delay a new pregnancy (lactation amenorrhea)
• Helps a mother return to pre-pregnancy weight

Benefits of Breastfeeding for the Family

• Better health, nutrition, and well-being

• Economic benefits
• breastfeeding costs less than artificial feeding
• breastfeeding results in lower medical care costs

Barriers to Breastfeeding
NUTRITION DURING INFANCY

Rapid growth during the first year of life differentiates infancy from all other ages. From birth
to 6 months of age, growth occurs most rapidly than at any other period in the life cycle.
Adequate nutrition is required for normal development of the brain.

Infancy is a critical period for formation of the brain. During this time, the foundation for
cognitive, motor, and socio-emotional skill development is established. These developmental
skills will continue to progress through childhood and adulthood. This is also the period when
feeding skills and healthful eating patterns are being established. Full brain development is
reached at the age of 25.

Calorie Allowances

At birth, a baby requires about 350 to 500 calories, and in one year, from 800 to 1,200 calories:
120 calories per kilogram body weight from the 2nd to the 7th month and 100 calories per kilogram
from 7th to the 12th month.

The average requirement for growth in the first year is 50 calories per pound of expected weight,
2/3 of this amount of needed calories being supplied by the milk and 1/3 by the added calories.

Protein Allowances

Allowances of 1.5 to 2.5 g of protein per kg in the body weight from 0 to 6 months of age, and
1.5 to 2 g per kg in the body weight from 6 to 12 months of age are recommended by the
FAO/WHO Expert Group.

Fat Allowances

Fat is an essential component in the diets of infants. It provides essential fatty acids, is a
concentrated source of energy, and facilitates the absorption of fat-soluble vitamins. Fat is
especially important in infancy and early childhood because it is essential for neurological
development and brain function. Infants are at higher risk for essential fatty acid deficiency
related to their rapid growth rate and higher requirements for polyunsaturated fatty acids. They
also have limited stores of body fat. Restrictions of fat and dietary cholesterol are not
recommended in infancy.

Other Nutrient and Non-Nutrient Needs

Fluoride
When ingested during the time that teeth are developing the fluoride will be deposited on tooth
surfaces. Fluoride helps to reduce tooth decay by decreasing the solubility of tooth enamel,
decreasing the production of acid by oral bacteria, and by supporting further remineralization.
Dental caries are the most common chronic disease of childhood.
Vitamin D
Vitamin D is a key nutrient in the diets of infants. It has an essential role in bone mineralization
and calcium and phosphorus homeostasis, and regulates genes associated with immune
response and cellular growth. There are two forms: vitamin D2 (ergocalciferol), which is from
plants and fungi, and vitamin D3 (cholecalciferol), which is synthesized in the skin during
exposure to sunlight. Vitamin D3 also is found in fatty fish like salmon and mackerel.

Iron
Iron Infants are at risk for iron deficiency because of rapid growth in the first year. From 4 to 12
months of age, an infant’s blood volume will double. Those with lower iron stores at birth or
low intakes of dietary iron are also at risk. Iron deficiency anemia in infancy is associated with
short and long-term consequences, including poor cognitive and motor development.

Feeding the Infant

Breastfeeding
The AAP and the Academy of Nutrition and Dietetics (AND) recommend that optimal nutrition
for infants be provided by exclusive breastfeeding for the first 6 months of life and continuation
of breastfeeding for the second 6 months. Breastfeeding is a key public health strategy for
improving infant health and reducing morbidity and mortality in the first 12 months.

Formula Milk (Cow’s Milk)

The American Academy of Pediatrics and the Academy of Nutrition and Dietetics Pediatric
Practice Group recommend that whole cow milk, skim milk, and reduced-fat milk not be used in
infancy. Iron-deficiency anemia has been linked to early introduction of whole cow’s milk. Low
iron availability may result from gastrointestinal blood loss or the lack of other iron-rich foods.

Complementary Feeding
The goals of infant feeding are to meet all nutritional needs, to enhance mother-infant bonding,
to assist the infant in initiating the transition from a primarily liquid diet to a predominantly solid
food diet in childhood, and to establish routines of eating in moderation. Complementary foods
are solid foods and fluids other than breast milk and formula.

Supplements for Infants

Specific supplements are recommended for breastfed infants in the United States and Canada,
under certain circumstances:

◗ Fluoride supplementation is recommended starting at 6 months of age for infants residing in

communities with low levels of water fluoridation.
◗ Iron supplementation is recommended for exclusively breastfed term infants starting at four
months of age at a dose of 1 mg/kg/d, and continued until iron-containing complementary foods
are introduced in the diet. Meat as an early complementary food for breastfed infants has been
associated with improved iron and zinc status.
◗ Vitamin B12 supplementation may be needed for breastfed vegan infants if the maternal diet
is inadequate. There are no unfortified plant food that contain significant amounts of the active
form of vitamin B12. Fermented soy products are not reliable sources of the active form of this
vitamin.

Common Disorders and Nutritional Issues During Infancy

Colic
Colic is described as a condition of irritability, and excessive, inconsolable crying in healthy, well-
fed infants. It can occur from early infancy up to 4 or 5 months of age, and can have a pattern of
onset and duration. The association of colic symptoms, gastrointestinal upset, and infant feeding
practices has been studied, but no definitive cause of colic has yet been identified.

Iron-Deficiency and Iron-Deficiency Anemia

Iron deficiency is the most common micronutrient deficiency throughout the world. Both iron-
deficiency anemia (IDA) and iron deficiency without anemia (ID) during infancy are of major
significance because of their relationship with neurodevelopment and behavior. Iron deficiency
is associated with poor cognitive, motor and socio-emotional development in infancy, and in later
childhood with poor cognition and school achievement.

Diarrhea and Constipation

Diarrhea is described as the passage of three or more loose, watery stools per day or a stool
volume greater than 10 grams per kilogram of body weight in infants. The cause of diarrhea
during infancy may or may not be identifiable. Diarrhea may result from viral and bacterial
infections, food intolerance, or changes in fluid intake. Excessive intake of fruit juice may be a
cause of diarrhea in older infants.

Diarrhea and Constipation

Constipation is defined as changes in the frequency, size, consistency, or easy of passing stool.
Difficulty with defecation is a common occurrence in infancy and childhood. The problem is often
short in duration and of little consequence. Recommendations for the infant with constipation
focus on normal fluid and fiber intake.

Early Childhood Caries (EEC)

Early childhood caries are also known as baby bottle caries and baby bottle tooth decay. Feeding
practices established in infancy may increase risk of EEC.

Food Allergies
The most common allergic reactions are respiratory and skin symptoms, such as wheezing or skin
rashes. Although food allergies can start in infancy, they are confirmed by specific laboratory
tests after infancy. True allergies can present as an array of reactions building up over time, so
that it may take several years for the initiating cause to be identified.
While there is no cure for a food allergy, food desensitization offers the best alternative. This
process is called oral immunotherapy treatment (OIT), an approach that desensitizes your body
to the allergen, allowing you to eat the food without the chance of an allergic reaction.

NUTRITION DURING CHILDHOOD YEARS

Childhood is a period of life from 1 to 12 years of age.

Toddlers are generally defined as children between the ages of 1 and 3 years. This stage of
development is characterized by a rapid increase in gross and fine motor skills with subsequent
increases in independence, exploration of the environment, and language skills.

Preschool-age children are between 3 and 5 years of age. Characteristics of this stage of
development include increasing autonomy; experiencing broader social circumstances, such as
attending preschool or staying with friends and relatives; increasing language skills; and
expanding ability to control behavior.

Importance of Nutrition

Adequate intake of energy and nutrients is necessary for toddlers and preschool-age children to
achieve their full growth and developmental potential. Undernutrition during these years impairs
children’s cognitive development as well as their ability to explore their environments. Long-term
effects of undernutrition, such as failure to thrive and cognitive impairment, may be prevented
or reduced with adequate nutrition and environmental support.

Calorie Allowances

Dietary Recommended Intakes have been established for the energy needs of young children.
The formula for Estimated Energy Requirements (EER) for children ages 13–36 months is (89 ×
weight of child [kg] – 100) + 20 (kcal for energy deposition). For example, a healthy 24-month-
old girl who weighs 12 kg would have an EER of (89 × 12 kg – 100) + 20 = 988 kilocalories.
Beginning at age 3, the DRI equations for estimating energy requirements are based on a child’s
gender, age, height, weight, and physical activity level (PAL).

Protein Allowances

About 1.5 to 2g/kg of body weight is required. The child’s protein requirement is relatively higher
in relation to body weight than that of an adult. The RENI indicates that the protein need per
kilogram of body weight decreases. The protein requirements are relatively high for periods of
rapid growth and lower during periods of slow growth.
Vitamins and Minerals

DRIs for vitamins and minerals have been established for the toddler and preschool-age child.
Most children from birth to 5 years are meeting the targeted levels of consumption of most
nutrients, except for iron, calcium, and zinc.

First 1000 Days

- Starts from conception up to the first two years of a child

- “golden window of opportunity” where health, nutrition, and development foundations
are established
- Its impact:
• Optimum growth and development
• Higher IQ and better performance in school
• Lower risk of diseases and overall better health
• Increased productivity and higher income
• Reduced child deaths

Malnutrition can be prevented particularly during the first 1,000 days of life

1. Antenatal multiple micronutrient supplementation to reduce risk of stillbirths, low

birthweight and small-for-gestational age babies;
2. Provision of supplementary food in food-insecure settings.
 3. Use of locally produced, ready to use supplementary and therapeutic food to manage
acute malnourished children;
4. Preventive small-quantity lipid based nutrient supplementation for children aged 6 to 23
months for positive effects in child growth.
5. Integrated interventions including diet, exercise, and behavior therapy for prevention and
management of childhood obesity;
6. Nutrition-sensitive programs that yield nutritional benefits including malaria prevention,
preconception care, and water, sanitation, and hygiene (WASH) promotion; and
7. Improved coverage of interventions to reach the most vulnerable groups.

Middle childhood is a term that generally describes children between the ages of 5 and 10 years.
Preadolescence is generally defined as ages 9–11 years for girls and ages 10–12 years for boys.
Both these stages of growth and development are also referred to as school-age.

Importance of Nutrition

Adequate nutrition continues to play an important role during the school-age years in ensuring
that children reach their full potential for growth, development, and health. Nutrition problems
can still occur during this age, such as iron-deficiency anemia, undernutrition, and dental caries.
Regarding weight, both ends of the spectrum are seen during this age.

Calorie Allowances

Allowances decline to about 80 to 90 kcal/kg for children 7 to 9 years old and 70 to 80 kcal/kg
for children aged 10 to 12 years old.

Protein Allowances

Approximately 37 g of protein is recommended daily for children 7 to 9 years old and 43 to 48 g

for children aged 10 to 12 years.

Vitamins and Minerals

Dietary Reference Intakes (DRIs) for vitamins and minerals have been established for the school-
age and preadolescent child. According to food-consumption surveys, children’s mean intakes of
most nutrients meet or exceed the recommendations. Still, certain subsets of children do not
meet their needs for key nutrients such as iron and zinc, which are important for growth, and
calcium, needed to achieve peak bone mass.