List of Abbreviations

AFASS Acceptable Feasible Affordable Sustainable Safe

BCC Behavior Change Communication
ELBW Extremely Low Birth Weight
HSS Health System Strengthening
MCH Maternal Child Health
MNCH Maternal Newborn and Child Health
UNICEF United Nations International Children Emergency Fund
VLBW Very Low Birth Weight

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TABLE OF CONTENTS

Acknowledgement.............................................................................................2
List of Abbreviations.........................................................................................3
Module Introduction.........................................................................................8
Module Competencies.......................................................................................9
Module Outcomes.............................................................................................9
Module Learning Strategies..............................................................................9
Module Learning Logistics/Resources...............................................................9
Module Assessment..........................................................................................9
UNIT 1: INTRODUCTION TO NUTRITION IN THE LIFESPAN...........................10
Unit objectives.............................................................................................10
1.1 Meaning of terms...................................................................................10
1.2 Nutrients requirement for normal body functions..................................10
1.3 Lifespan stages......................................................................................13
1.4 Importance of nutrition in the lifespan...................................................13
1.5 Nutrition Vulnerability...........................................................................13
1.5.1 General factors influencing vulnerability.............................................14
1.6 Factors that determine an individual’s nutritional needs.......................15
UNIT 2: INTRODUCTION TO MATERNAL AND CHILD HEALTH...................16
Unit objectives.............................................................................................16
2.1 Meaning of terms...................................................................................16
2.2 Components of Maternal Child Health...................................................16
2.3 Importance of maternal child services....................................................17
UNIT 3: PRE-CONCEPTION NUTRITION.........................................................18
Unit objectives.............................................................................................18
3.1 Pre-conception nutrition in Men and Women.........................................18
3.2 Importance of pre-conception care.........................................................18
UNIT 4: NUTRITION IN PREGNANCY..............................................................20
Unit objectives.............................................................................................20
4.1 Meaning of terms...................................................................................20

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 4.2 Importance of pre-natal care..................................................................20
4.3 Stages of pregnancy...............................................................................21
4.4 Pregnancy related complications and their nutritional management. . .21
4.5 Physiological changes of pregnancy.......................................................22
4.6 Nutrition requirements in pregnancy.....................................................23
4.7 Factors affecting pregnancy outcome.....................................................27
UNIT 5: NUTRITION IN LACTATION...............................................................29
Unit objectives.............................................................................................29
5.1 Meaning of Terms..................................................................................29
5.2 The Anatomy of the Breast.....................................................................29
5.3 Possible signs that a baby is not getting enough breast milk.................32
5.4 Factors contributing to vulnerability in lactating mothers......................32
5.5 Nutrition requirements in Lactation.......................................................33
5.6 Breastfeeding.........................................................................................34
5.6.1 Hormonal control of lactation...........................................................34
5.6.2 Milk composition (quality and quantity)...........................................34
5.6.3 Breastfeeding and lactation Suckling...............................................35
5.6.4 Contraceptives and lactation............................................................35
5.6.5 Importance of breastfeeding.............................................................35
5.6.6 Breastfeeding Complications............................................................36
5.6.7 What to avoid during lactation.........................................................38
UNIT 6: NUTRITION IN 0-6 MONTHS............................................................40
Unit Objectives............................................................................................40
6.1 Developmental milestones.....................................................................40
6.2 Vulnerable newborns.............................................................................41
6.3 Infant Feeding options...........................................................................42
6.4 Characteristics of good infant feeding options........................................44
UNIT 7: NUTRITION IN 6 -24 MONTHS...........................................................45
Unit Objectives............................................................................................45
7.1 Meaning of terms...................................................................................45

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 7.2Developmental milestones......................................................................45
7.3 Complementary feeding.........................................................................45
7.4 Risk of early complementary feeding......................................................47
UNIT 8: NUTRITION FOR PRE-SCHOOLERS (25- 59 MONTHS).....................48
Unit Objectives............................................................................................48
8.1 Meaning of terms...................................................................................48
8.2 Developmental milestones.....................................................................48
8.3 Nutritional requirements.......................................................................48
8.4 Feeding habits.......................................................................................50
8.5 Nutrition and health problems in pre-schoolers.....................................50
UNIT 9: NUTRITION FOR SCHOOL GOING CHILDREN..................................51
Unit Objectives............................................................................................51
9.1 Meaning of terms...................................................................................51
9.2 Nutrition and Health problems for the school-going children.................51
9.3 Nutrition requirements for the school going...........................................51
UNIT 10: NUTRITION IN ADOLESCENCE.......................................................54
Unit Objectives............................................................................................54
10.1 Meaning of terms.................................................................................54
10.2 Body changes in adolescence...............................................................54
10.3 Nutrition and Health problems in adolescence.....................................55
10.4 Nutrition requirements during adolescence..........................................55
10.5 Increased Nutritional Needs.................................................................57
10.6 Factors influencing dietary intake of adolescents.................................58
10.7 Nutritional concerns in adolescence.....................................................58
10.8 Nutrition education and counseling of the youth.................................60
UNIT 11: NUTRITION IN ADULTHOOD...........................................................61
Unit Objectives............................................................................................61
11.1 Meaning of terms.................................................................................61
11.2Nutrient requirements for adults..........................................................61
11.3 Factors influencing dietary intake in adults.........................................62

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UNIT 12: GERIATRIC NUTRITION...................................................................63
Unit Objectives............................................................................................63
12.1 Meaning of terms.................................................................................63
12.2 Physiological changes in old age..........................................................63
12.3 Nutrient requirements for the elderly...................................................65
12.4 Factors influencing dietary intake in the elderly..................................67
12.5 Intervention strategies for geriatrics.....................................................67
12.6 Common elderly persons nutrition- related problem............................67
REFERENCES................................................................................................69

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Module Introduction
Nutrition in the Lifespan module is designed to equip the learner with
knowledge, skills and attitude to enable them to construct healthful dietary
patterns for different stages of the lifecycle.The prerequisite modules include;
Human anatomy and physiology, Principles of human nutrition, Introduction
to Nutrition and Dietetics. The module takes 60 contact hours: 36 hours for
theory and 24 hours for practical.
Learners undertaking this module will have both theory and practical
assessments. The formative assessment will be in the form of continuous
assessment tests, assignments, clinical and field assessments and promotional
examination whereas summative assessment will be done in form of final
qualifying examination.

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Module Competencies
Provide the learner with relevant knowledge; skills and attitudes through the
life cycle.
Module Outcomes
1. Describe the factors that influence individual nutritional needs
2. Describe the nutrient needs during the different stages of the lifecycle
3. Construct healthful dietary patterns for the different stages of the
lifecycle
4. Explain the diseases associated with deficiencies during the various
stages
5. Identify emerging issues affecting nutrition in the lifecycle

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UNIT 1: INTRODUCTION TO NUTRITION IN THE LIFESPAN
Unit objectives
By the end of this unit, the learner should be able to:
1. Define key terms used in the nutrition in the lifespan
2. Explain the nutritional requirements for normal body functions
3. List the lifespan stages and the importance of nutrition in the lifespan
4. Explain general factors leading to vulnerability
1.1 Meaning of terms

Nutrition in the life cycle: People at all stages need the same basic nutrients;
essential amino acids, carbohydrates, essential fatty acids, and twenty eight
vitamins and minerals to sustain life and health. However, the amounts of
nutrients needed differ throughout the human life cycle. The span of a human
life, which consists of different stages, including childhood, adolescence,
adulthood, and old age, the body constantly changes and goes through
different periods known as stages.
Vulnerability:Vulnerability in this context can be defined as the diminished
capacity of an individual or group to anticipate, cope with, resist and recover
from the impact of a natural or man-made hazard. The concept is relative and
dynamic. Vulnerability is most often associated with poverty, but it can also
arise when people are isolated, insecure and defenseless in the face of risk,
shock or stress.
People differ in their exposure to risk as a result of their social group, gender,
ethnic or other identity, age and other factors. Vulnerability may also vary in
its forms: poverty, for example, may mean that housing is unable to withstand
an earthquake or a hurricane, or lack of preparedness may result in a slower
response to a disaster, leading to greater loss of life or prolonged suffering.
Vulnerable groups: these are the specific individuals in the populations whose
capacity or ability to anticipate, cope with, resist and recover from an impact of
a natural or man-made hazard is diminished or limited.

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1.2 Nutrients requirement for normal body functions
Basic nutrients—essential amino acids, carbohydrates, essential fatty acids,
and twenty-eight vitamins and minerals—to sustain life and health
1.2.1 Macronutrients: Carbohydrates, Protein, and Fats
The foods you eat provide the energy your body needs to work. Just like you
need to put fuel in your car or recharge your cell phone battery, your body
needs to be fed food that provides it with energy every day.
Glucose is the body's favorite form of energy. Carbohydrates are broken down
into glucose as well as fructose and galactose units. If you don't get enough
carbohydrates, your body can make glucose from protein through a processed
called gluconeogenesis. If you consume too many carbohydrates, your body will
convert them into fat, used then for storage in your adipose tissue.
Protein comes from foods you eat and is broken down into individual amino
acids. The body uses these amino acids to build and repair the various parts of
itself. Also, muscles contain lots of protein which needs to be replenished
through diet. The body even uses protein towards its immune system,
hormones, nervous system, and organs.
In terms of fats, the body needs them and needs them to be of the healthy
variety. Not only are fats required to signal hormones, but membranes that
contain fats surround all the cells of the body.Even the brain has fatty acids.
1.2.2 Micronutrients: Vitamins and Minerals
The vitamins and minerals from the diet are just as important as the
carbohydrates, protein, and fats (even though you only need them in small
amounts).
They usually function as co-enzymes, which mean they help speed up some of
the body's chemical reactions. For example:
 Many B-complex vitamins help burn carbohydrates for energy.
 Vitamin A is needed for vision.
 Zinc is involved in many metabolic processes.

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  Vitamin C helps keep connective tissue strong and the immune system
functioning.
 Vitamin D is essential for proper calcium uptake.
Speaking of calcium, it's probably the best known dietary mineral. It has
several functions in the body. But the reason you hear or read about calcium
so much is because lots of it is stored in your bones and teeth. Therefore, you
need it from your diet to keep your bones and teeth strong. Another mineral
you've probably heard a lot about is iron.
Although you don't need as much iron as calcium, it's essential for your cells to
get enough oxygen. 
 Fat-Soluble Vitamins
 Water-Soluble Vitamins 
 Major Minerals 
 Dietary Trace Minerals
Your diet needs to provide adequate amounts of all of these "little helpers." And
a healthy, balanced diet will give you lots of vitamin and minerals.An
unhealthy diet may make the body deficient in one or more of them.
1.2.3 Antioxidants and Phytochemicals
Good nutrition provides more than energy, structural components, vitamins,
and minerals.  Antioxidants help protect the body from damage that comes
from the sun, pollution, smoke, and poor dietary choices. They are the
phytochemicals in fruits and vegetables (responsible for the bright colors).
Some vitamins and amino acids even function as antioxidants as well.
Phytochemicals are antioxidants found in plant-based foods. Although they
aren't required for body function, they may have a very powerful impact on
your health. For example, quercetin (found in red apples) operates like an
antihistamine and has an anti-inflammatory effect.

1.2.4 Eating a Healthy Diet

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A healthy diet will give your body the right amount of energy, enough raw
materials, and all the "little helpers" you need to stay healthy. Good nutrition
will also provide phytochemicals and antioxidants that will help keep you
feeling young, looking great, and perhaps even disease-free. 
Essentially, a healthy diet includes lots of fruits and vegetables, some whole
grains, high-quality protein, enough dairy or other calcium sources, and a bit
of healthy fat. And while you don't want to deny yourself a few treats and the
foods you love, it's best to cut back on unhealthy foods that are high in sugar,
fat, sodium, and calories. That's where portion control comes in handy.

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1.3 Lifespan stages
Pregnancy: The development of a zygote into an embryo and then into a fetus
in preparation for childbirth.
Infancy: The earliest part of childhood. It is the period from birth through age
one.
Toddler years: Occur during ages two and three and are the end of early
childhood.
Childhood: Takes place from ages four to eight.
Puberty: The period from ages nine to thirteen, this is the beginning of
adolescence.
Older adolescence: The stage that takes place between ages fourteen and
eighteen.
Adulthood: The period from adolescence to the end of life and begins at age
nineteen.
Middle age: The period of adulthood that stretches from age thirty-five to fifty
five
Old age: Extend from age fifty-five until the end of life.

1.4 Importance of nutrition in the lifespan

Nutritional status and nutritional requirement are explored using a life span
model. From a multiple determinant perspective, nutrition is positioned as a
significant factor affecting health at each life stage. The importance of nutrition
on the developing foetus, and its impact on development of chronic disease in
later life is critical. Emphasis is placed on nutrient requirements, adaptation,
growth and development as well as current areas of research and controversy
at each stage of the life cycle. Areas of emphasis include feeding and eating
principles, high risk populations, women's health needs, and nutrition
challenges presented by our aging society. Relevant health and education
policy, program and evaluation strategies are presented.

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Nutrition is the intake of food, considered in relation to the body’s dietary
needs. Good nutrition – an adequate, well balanced diet combined with regular
physical activity – is a cornerstone of good health. Poor nutrition can lead to
reduced immunity, increased susceptibility to disease, impaired physical and
mental development, and reduced productivity.
1.5 Nutrition Vulnerability
As defined earlier, the following are the vulnerable stages in the lifecycle:
 Foetal stage (-9 to 0 months): intra-uterine nutrition impacts on birth
weight and micronutrient stores after birth e.g. calories, iron, iodine and
Vitamin A
 Infancy: Depending on feeding practices and other environmental factors
that influence childcare and childhood illnesses’ prevalence, severity and re-
occurrence. This can also influence survival of the infant.
 Young childhood (Under five years): Depending on feeding practices and
other environmental those influence childcare and childhood illnesses’
prevalence, severity and re-occurrence. This can also influence child
survival.
 Women of reproductive age (beginning with adolescents): Women of
reproductive age are particularly vulnerable due to the nutrient losses they
face through monthly menses, pregnancies, deliveries and lactation. Women
of this age, especially in resource limited settings are also usually involved
in energy demanding activities in their daily life. The problem is
compounded by food insecurity and poverty which means that the body is
mostly under-nourished and cannot match its nutrient needs.
 Pregnant women: The woman may get into pregnancy already malnourished
(underweight and micro-nutrient deficiencies). She has now to share her
already low nutrient stores with the foetus. This can lead to depletion of
these stores and/ or deficiencies, especially if there is no improvement in
the dietary intake.

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 Lactating women: If the woman gets into lactation and breastfeeding after
pregnancy already malnourished (underweight and micro-nutrient
deficiencies), it could lead to further depletion of her nutrient stores and/ or
deficiencies, especially if there is no improvement in her dietary intake.
 The elderly due to the fact that most of them have reduced physical
functioning and interventions do not target them.
 Others: prisoners, refugees, orphans, physically challenged and street
families.

1.5.1 General factors influencing vulnerability

 Age  Ethnic factors
 Economic factors e.g. income and  Physiological factors
finances  Poverty e.g. food insecurity
 Cultural factors e.g. food taboos  Geographical factors
 Natural calamities  Poor infrastructures
 Environmental factors  Disabilities
 Gender
 Social factors e.g. family size, marital status ,single ,literacy level, ignorance,
lack of knowledge
 Global climatic change
 Health factors e.g. Nutritional status, Diseases and Infections
1.6 Factors that determine an individual’s nutritional needs.
 Calories are simply how we describe food energy – the energy your body
needs to flourish. There are three factors that influence how many
calories your body needs
 Pregnancy and Lactation
 Sociocultural factors e.g. religion and culture
 Age
 Gender
 Growth

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 Physical activity
 BMR
 Disease state
 Poverty
 Parasites

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UNIT 2: INTRODUCTION TO MATERNAL AND CHILD HEALTH
Unit objectives
By the end of this unit, the learner should be able to:
1. Define terms used in maternal and child health
2. Describe components of maternal and child health
3. Explain the importance of maternal and child health services
4. Visit a health facility and identify the components of MCH4
2.1 Meaning of terms
MCH- promotive, preventive and rehabilitative health care for mother and
children
Maternity- Period of a woman during pregnancy and continues after child
birth
Neonatal period- First 28 days of life
Post neonatal period- 28th day to 1 year
2.2 Components of Maternal Child Health
 Family Planning/Reproductive Health (FP/RH) delivers services and
improves the quality of care provided in the public and private health
sectors.
 Maternal Newborn and Child Health (MNCH) Services introduce and
expand high impact and evidence based maternal, neonatal, and child
health interventions while incorporating birth spacing and family
planning care into public and private sector services.
 Behavior Change Communications (BCC) use commercial marketing
techniques and behavior change communication strategies to increase
family planning services, pre and postnatal care services, and increase
availability and access to affordable services and commodities.
 Health Commodities procure health commodities and provides
technical assistance to strengthening the capacity to forecast, purchase,
and distribute health products.

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 Health Systems Strengthening (HSS) provide technical assistance to
reform and improve the delivery and management of health

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2.3 Importance of maternal child services.
 Prevents maternal mortality
2.3.1 Postnatal care
The importance of postnatal care includes::
 Support of breastfeeding
 Educate on nutrition and supplementation
 Counseling on contraception and resumption of sexual activity
 Immunization for infants
 Prevention, early diagnosis and treatment of complications
 Support mother and the family
2.3.1.1 Benefits of proper postpartum care
 Ease of the body returning to pre pregnancy state
 Enjoy motherhood
 Feel less tired and fatigued
 Better milk supply
 Gain self-confidence. Happier baby due to the bond between mother and
child

Students activity
Practical- Visit a Health Facility to understand the different components of
Maternal and Child Health

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UNIT 3: PRE-CONCEPTION NUTRITION
Unit objectives
By the end of this unit, the learner should be able to:
1. Understand the concept of preconception nutrition in men and women
2. Explain the importance of preconception nutrition care in men and
women
3.1 Pre-conception nutrition in Men and Women
Adequate nutrition before conception has the potential to have long-term
health impacts on both the mother and the yet to be conceived child. It helps
ensure that the baby has an optimal environment to grow in, and reduces the
chances of deficiencies that may result in birth defects. In addition, it improves
fertility and the chances of conception. It is recommended that both the male
and female focus on good nutrition, a healthy lifestyle and increased fitness, at
least 6 months prior to conception. This will help to optimize the sperm quality
and quantity, and prepare the female body for a successful pregnancy and
delivery. A woman planning to conceive should evaluate whether or not she has
enough nutrient stores to carry a pregnancy for nine months. This underscores
the importance of women making conscious decisions about their reproductive
health – when to have children and preparing the body to support the
pregnancies.

3.2 Importance of pre-conception care.

3.2.1 Importance of pre-conception care for men
 Make a plan and take action- it involves a reproductive life plan
 Prevent and treat STDs- Involves protecting the woman from STDs
during pregnancy. STDs may result to complications for the unborn child
and infertility for the woman
 Avoid smoking, use of drugs and excessive alcohol intake as it may lead
to infertility in men. Exposing a woman to these increases the chance of
having a low birth weight infant

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 Avoiding toxic substances e.g. fertilizers, chemicals can lead to diseases
and infertility
 Prevent infertility. Some things that can reduce the health or number of
sperms include: type 1 diabetes, age, obesity, diseases, chemicals,
radiation treatments
 Reach and maintain healthy weight. Obesity in men is associated with
increased chances of infertility
 Support to the partner and ensure proper mental health

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3.2.2 Importance of pre-conception care for women
 Attain healthy weight
 Control medical conditions
 Ensure immunizations are up to date
 Develop a plan for the reproductive life
 Increase daily intake of folic acid
 Avoid use of drugs and alcohol

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UNIT 4: NUTRITION IN PREGNANCY
Unit objectives
By the end of this unit, the learner should be able to:
1. Define terms used in pregnancy
2. Describe the factors contributing to vulnerability in pregnancy
3. Describe the nutritional requirements in pregnancy
4. To understand concept of nutrition in pregnancy

4.1 Meaning of terms

Prenatal care: Prenatal care, also known as antenatal care is a type of
preventive healthcare with the goal of providing regular check-ups that allow
doctors to treat and prevent potential health problems throughout the course
of the pregnancy while promoting healthy lifestyles that benefit both mother
and child.
Miscarriage - Loss of the embryo or fetus and other products of pregnancy
before the twentieth week. Often, early in a pregnancy, if the condition of the
baby and/or the mother’s uterus is not compatible with sustaining life, the
pregnancy stops, and the contents of the uterus are expelled. For this reason,
miscarriage is also referred to as spontaneous abortion.
Ovary- One of the two almond-shaped glands in the female reproductive
system responsible for producing eggs and the sex hormones estrogen and
progesterone.
Teratogen -any drug, chemical, maternal disease, or exposure that can cause
physical or functional defects in an exposed embryo or fetus.
Uterus (womb)- the female reproductive organ that contains and nourishes a
fetus from implantation until birth.
4.2 Importance of pre-natal care
 Reduces risk of pregnancy complications and inform women about the
important steps they can take to protect their infants and ensure a
healthy pregnancy.

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With regular prenatal care, women may:
 Follow a healthy safe diet as advised by the health care provider
 Control serious existing conditions
 Reduce infants and fetus risks of complications
 Help ensure the medications the women take are safe
 Help keep track of the fetal development
 Learn about labor, delivery and different issues relating to pregnancy
4.3 Stages of pregnancy
Gestation is the period of embryo development from conception to birth.
Gestation is about 40 weeks in humans and is divided into three trimesters,
each spanning 3 months. Gestational stages are also based on physiological
fetal development, which include blastogenesis, embryonic stage and fetal
stage.
Blastogenesis is the stage from fertilization to about 2 weeks. The fertilized egg
or the zygote becomes a blastocyst where the outer layer and the inner cell
mass differentiate to form placenta and the fetus respectively. Implantation
occurs at this stage where the blastocyst becomes buried in the endometrium.
Embryonic stage is approximately from 2 weeks to 8 weeks. It is also in this
stage where the blastocyst develops into an embryo, where all major features of
human are present and operational by the end of this stage.
Fetal stage is from 9 weeks to term. During this period of time, the embryo
develops rapidly and becomes a fetus. Pregnancy becomes visible at this stage.

4.4 Pregnancy related complications and their nutritional management

a) Food Cravings/ Aversions and Pica
Pica is the desire for non-food items. The nutritional management for food
cravings include: Eating small frequent meals that are nutrient dense and
psychosocial counseling
Food aversions is the avoiding of certain foods and food cravings is the desire
for some foods

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b) Hemorrhoids
They are varicose veins of the rectum and are usually very painful
The causes may include constipation combined with prolonged standing.
Nutritional management of hemorrhoids include: Avoiding constipation, taking
plenty of fluids, taking a high fiber diet, exercise, avoiding delay in bowel
movement and consumption of plenty of fruits
c) Morning sickness
It is accompanied with nausea and vomiting which may be due to low levels of
vitamin B6 and hormonal changes due to the presence of the fetus.
Hyperemesis gravidarum is the severity of morning sickness and involves
excessive vomiting and being unable to tolerate most foods. Management
includes taking small frequent meals, avoiding taking fluids with meals,
restrict fatty foods and foods high in seasoning and consumption of dry
carbohydrate foods in the morning
d) Heartburn
It is a burning sensation and acidic taste in the mouth and throat. The causes
include increased levels of hormones leading to softening of the ligaments and
more pressure on stomach as the baby grows leading to stomach contents
going up the GIT
Management:
 Avoiding foods that trigger heartburn e.g. citrus, chocolate
 Avoiding drinks containing caffeine
 Avoiding alcohol because it relaxes the lower esophageal sphincter
 Avoid eating big meals
 Sleep with head propped up
 Avoid taking antacids
e) Constipation
It is infrequent and difficult painful passage of stool. The causes include
 Low dietary habits
 Poor bowel movement

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 Hormonal disorders
 Abuse of laxatives
 Minimal physical exercise
Management includes increasing foods high in soluble fibers, avoid the use of
laxatives unless recommended, taking small meals and exercise
4.5 Physiological changes of pregnancy
a) Weight gain
Weight gain occurs mostly during the last 20 weeks of gestation. About 40 % of
this weight is represented by the fetus, placenta and amniotic fluid and 60% is
the maternal weight change which results from increased fluid volume, protein
deposition and fat stores. These changes are from increased mammary,
uterine, kidney and heart tissue volume

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b) Blood volume
Increase in blood volume is needed to provide for extra blood flow to the uterus,
extra metabolic needs to the fetus and increased perfusion of other organs.
There is an increase in hemoglobin concentration until about the 13 th week
because plasma volume increases more than the red blood cell volume
c) Cardiovascular changes
There is an increase in cardiac output due to the blood volume in the uterus,
placenta and kidneys.
d) Respiratory changes
There is increased oxygen use due to an increase in BMR and body size.
e) Metabolic changes
An increase in BMR results from an increase in different hormones resulting
from alterations in carbohydrate, protein and fat use.
f) Kidney changes
There is an increase in blood flow to ease clearance of waste products. There is
also a decrease in ability to excrete water due to an increased production of
steroid hormone by the placenta and adrenal cortex which enhances
reabsorption of sodium, chloride and water by renal tubules.
An increase in renal frequency results from relaxation of the ureter and the
enlarging uterus displaces the urinary bladder upwards
g) Gastrointestinal changes
There is slow gastric emptying time which enhances absorption of some
nutrients. There is increased absorption of water which causes constipation
due to decreased muscle tone
4.6 Nutrition requirements in pregnancy
During pregnancy, the body goes through a lot of hormonal, physiological, and
physical changes thus has increased nutritional needs. Although the old saying
"eating for two" isn't entirely correct, more macronutrients and micronutrients
are indeed required during pregnancy.  Generally, most women can meet these
increased nutritional needs by choosing a diet that includes a variety of

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nutritious foods, including 8 to 10 glasses of water a day, and by taking a
nutrient supplement prescribed by their health care provider. A simple way to
ensure that mother and baby are getting all the nutrients needed is by taking a
variety of foods from each of the food groups daily.
4.6.1 Additional daily requirements for a pregnant woman
Nutrient Additional daily requirements for a pregnant woman
Calories 300- 350gms (in the second and third trimesters)
Protein 60 gms
Calcium 1200 mg
Folate 15 mg
Iron 30 mg

4.6.1.2 Essential Fatty Acids

Essential fatty acids (linoleic acid and linolenic acid) are very important for the
baby's normal retinal and brain development. Pregnant women are encouraged
to include some sources of essential fatty acids in their daily eating pattern.
Sources of essential fatty acids include: soybean, non-hydrogenated
margarines, oily fish, nuts and seeds.
4.6.1.3 Calories
 It is recommended that pregnant women eat an average of 150 calories more
per day in the first trimester and 350 calories more per day in the two
subsequent trimesters than they did before becoming pregnant. This is so as to
ensure adequate weight gain throughout the pregnancy. Calories are required
for normal growth and birth weight, and for fat stores to be used during
lactation.
4.6.1.4 Complex Carbohydrates
 A pregnant woman's calories should come from all three energy sources
(Macro-nutrients) - proteins, fats, and complex carbohydrates. A carbohydrate

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restricted diet during pregnancy puts the foetus at risk. Without
carbohydrates, the body will burn proteins and fat for fuel. This will lead to:
4.6.1.5 Protein
Adequate protein is vital since they are the building blocks of all materials in
the growing foetus (brain cells, hair, nails and other tissues). It is also needed
for the buildup of the mother’s muscles, uterus, breasts and blood supply. Low
protein intake is related to smaller-than-average weight babies who may have
health problems.
Animal products have all the essential amino acids and are considered
complete proteins. Vegetarian sources lack in one or more of the essential
amino acids and are considered incomplete proteins unless they are combined
properly. About 60-80 grams of protein is required daily by pregnant women (6-
8 servings).Vegetarians should combine a serving form the bean column with
complex carbohydrates and nuts or dairy to have a "complete" protein meal.
4.6.1.6 Zinc
Inadequate levels during pregnancy can cause prolonged labour and low birth
weight babies with health problems. The dietary intake for zinc should be 11-
12 milligrams per day.
4..6.1.7 Calcium and Vitamin D
 Adequate Calcium and vitamin D are important for both mother and baby
during pregnancy. The two nutrients work together to build strong bones and
teeth for the baby. They also help to keep the mother’s bones and teeth strong
throughout pregnancy, preventing maternal bone loss. When the mother’s diet
is low in calcium during the pregnancy, the baby will draw off maternal stores
to get the calcium it needs to develop. This can put the mother at increased
risk for osteoporosis and dental problems. A low calcium diet can also lead to
insomnia, irritability and leg cramps. About 1200-1500mg of calcium is
required daily. Some good sources of calcium and vitamin D include: milk,
yogurt, cheese, broccoli, orange juice with added calcium and fortified
soymilk. Kales, almonds, and fishes eaten with bones like ‘omena’, sardines

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and salmons are also rich in calcium. It is however important to remember that
phosphorus in sodas, and oxalic acid in spinach, beet greens, and chocolate
decrease the absorption of calcium. Also important to know, is that some
vitamin D is made by the skin from exposure to the sun.
4..6.1.8 Iron
Pregnant women need more iron than usual because their body is
manufacturing more blood - blood volume increases by 60% in pregnancy. Iron
supplies oxygen and nutrients to the foetus, supports placental function,
manufactures red blood cells, and acts as insurance against blood loss during
delivery. Iron from meat is better absorbed than from plants. Iron from plants
is absorbed better if taken with vitamin C or meat protein. Coffee, tea, bran,
and calcium decrease absorption.
It is practically not possible to get enough iron from food and so supplements
are usually recommended. The dietary reference intake for iron is 27
milligrams per day for all pregnant women. Without adequate iron, the foetus
will draw its supply from the mother, often leaving her anaemic. Routine
preventive iron supplementation for all pregnant women is recommended. In
the third trimester the baby will begin creating its own iron reserve for its first
six months of life when it will be primarily living on milk which is low in iron.
4..6.1.9 Folate/folic acid
 As we saw in the previous lecture, Folate/folic acid helps to decrease the risk
of neural tube defects that affect a baby's spine and brain, such as spina
bifida. Folate is the form of the vitamin found in food and folic acid is the form
found in pills. It is especially important for women to take a multivitamin that
contains 0.4mg of folic acid before becoming pregnant and during the first few
months of pregnancy. Although a multivitamin is recommended this does not
reduce or replace the need to make healthy food choices. In the previous
lecture, we looked at the consequences of folate deficiency.
4..6.1.10 Iodine

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As we discussed in the previous lecture, Iodine is required for the synthesis of
thyroid hormones that in turn are required for the regulation of cell metabolism
throughout the life cycle. We said that thyroid hormones ensure normal
growth, especially of the brain, which occurs from foetal life to the end of the
third post-natal year.
4.6.2 Consequence of iodine deficiency on intelligence
 Impaired thyroid function resulting from severe iodine deficiency during
pregnancy, resulting in a lower metabolic rate, growth retardation, brain
damage, increased perinatal mortality, and other defects
 Goiter (enlargement of the thyroid),Endemic cretinism, especially in
women before and during pregnancy
 Irreversible mental retardation, resulting from iodine deficiency during
pregnancy. Iodine deficiency is the most prevalent cause of preventable
mental retardation in the world.
The following practices can help expectant women get the nutrients needed for
a healthy pregnancy:
 Taking a variety of foods from each food group, and limit use of the oils
and solid fats.
 Eating regular meals
 Taking breakfast every day
 Eat healthy snacks between meals - Follow your appetite. When you are
hungry between meals choose healthy foods such as yogurt, fruit,
vegetables, oatmeal muffins, whole grain biscuits, nuts, etc.
 Taking a prenatal vitamin daily - Remember a prenatal vitamin does not
reduce or replace a healthy diet. It will help you get the extra vitamins
and minerals you need while you are pregnant.
 Eating 7-8 servings of fruits and vegetable each day. Choose colourful
vegetables and fruits whenever you can. These are a great source of
folate, vitamins and fibre.

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  Eating 6-7 servings of Grain products each day - Choose whole grain
breads, cereals, crackers, pasta and rice. Grain products are a great
source of carbohydrate (energy), iron and fibre.
 Eating 2 servings of milk and dairy products each day - are all great
sources of calcium and protein. Non-dairy foods that also contain
calcium are salmon with the bones, broccoli, and almonds.
 Eating 2 servings of meats and other proteins each day - For a great
source of iron and protein choose leaner meat, fish, poultry, eggs, lentils,
beans, tofu and peanut butter.
 Taking 30 grams of dietary fibre every day.
 Taking 8 or more glasses of water each day.
 Salt to taste.
4.7 Factors affecting pregnancy outcome
 The nutritional status of the mother during pregnancy.
 The diet of the mother during pregnancy.
 The health care of the mother during pregnancy.
 Intervals of pregnancies.
 The age of the mother e.g. adolescents or old age.
 The pre-pregnancy weight.
 The number of previous pregnancies.
 Diseases e.g. cardiovascular, hypertension, diabetes mellitus and
HIV/AIDs.
 Alcoholism and smoking by the pregnant mother (lifestyle habits).
 The workload of the mother.
 Mothers of multiple births like twins, or triplets.
 Cultural beliefs and taboos.
 Socio-economic status like poverty, lack of family support, low levels
of education and limited food available.
 Intra-household food distribution.

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Page 32 of 83
UNIT 5: NUTRITION IN LACTATION
Unit objectives
By the end of this unit, the learner should be able to:
1. Define terms used in lactation
2. Understand the anatomy of the breast and the concept of breastfeeding
3. Explain the factors leading to vulnerability in lactation
4. Describe the nutritional requirements in lactation
5.1 Meaning of Terms
Lactation- Secretion of milk from specialized glands to provide nourishment of
off springs
Let-down- Movement of milk from the alveoli through the duct system and
lactiferous sinuses to the nipple
Latch-on- When nursing infants grasp the nipple and a portion of the
surrounding areola in their mouths. A good portion of the areola should be
grasped for the successful suckling
Rooting reflex- A reflex in which infants will turn and open their mouths
towards the cheek that is brushed
Parturition- Process of giving birth
Lactational amenorrhea- Lack of menstruation associated with breastfeeding
Lactogenesis- It is the onset of milk secretion. It is a series of cellular changes
whereby mammary epithelial cells are converted from non-secretory state to
secretory state

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5.2 The Anatomy of the Breast
3/2

Anatomy of the breast

Oxytocin makes
Muscle cells them contract
Prolactin makes
Milk-secreting cells
them secrete milk
Ducts

Larger ducts

Nipple

Areola
Montgomery’s glands
Alveoli
Supporting
tissue and fat

This diagram shows the internal structure of the breast.

Alveoli are the glandular tissue where milk is produced and stored till it is
released by baby’s suckling.
Milk travels from the alveoli, through milk ducts, into the milk
sinuses (reservoirs that lie under the areola.)
3/3

Prolactin
• Secreted during and after feed to produce next feed

Sensory impulses from

nipples

Prolactin in blood

Baby suckling
• More prolactin
secreted at night
• Suppresses ovulation

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 3/4

Oxytocin reflex
• Works before or during feed to make milk flow

Sensory impulses from

Oxytocin in blood nipples

Baby suckling
• Makes uterus contract

3/11

Reflexes in the baby

Rooting Reflex
When something touches lips,
baby opens mouth, puts tongue Sucking Reflex
down and forward
When something touches
palate, baby sucks
Skill
Mother learns to
position baby
Baby learns to
take breast

Swallowing Reflex
When mouth fills with
milk, baby swallows

5.2.1 Positioning and attachment

1. Keep the baby’s body in a straight line with the whole body facing the
breast
2. Support the neck, shoulders and back so the baby can tilt his/her head
back easily
3. Move the baby from the cleavage towards the nipple
4. Make sure the baby’s lower lip and chin is in contact with the breast first

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 3/8

Good and poor attachment

What differences do you see?

1 2 5.3Possible signs that

a baby is not getting
enough breast milk
• Baby not satisfied after breastfeeds
• Baby cries often
• Very frequent breastfeeds
• Very long breastfeeds
• Baby refuses to breastfeed
• Baby has hard, dry, or green stools
• Baby has infrequent small stools
• No milk comes out when mother expresses
• Breasts did not enlarge (during pregnancy)
• Milk did not ‘come in’ (after delivery)
5.4 Factors contributing to vulnerability in lactating mothers
 Health of the mother: e.g. on diseases like cancer, diabetes, hypertension
and HIV/AIDS
 The nutritional status of the mother
 Economic status of the mother
 The age of the mother
 Cultural factors

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 Increased nutritional requirement e.g. energy requirement
 Social factors e.g. single mothers.
 Workload
 Illiteracy levels
 Family size
 Income
 Psychological factors e.g. stress
 Poor feeding practices due to lack of food, lack of knowledge, ignorance
and economic factors.
 HIV/AIDS status of the mother

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5.5Nutrition requirements in Lactation
The nutrition demands in lactation are greater than those of pregnancy. Infants
double their birth weight in the first 4 to 6 months of postpartum period. Most
recommendations of nutrients in lactation take into account the quantity of
milk produced, nutrient and energy content of the milk produced and maternal
energy and nutrient reserves.
The requirements include:
Calories: The energy and nutritional requirements of women who breastfeed
are greater than that of women who are not. Women who breastfeed exclusively
usually need an additional 500-550 calories per day to maintain their
weight. Despite the fact that dietary intake has little impact on the milk
production of a woman, a breastfeeding woman should consume at least 1500
calories per day to avoid excessive weight loss, which could affect the breast
milk output.
Protein: Very low protein intakes results in a reduction in the quantity rather
than quality of milk. A daily intake of 15 grams for the first 6 months followed
by 12 grams per day there after is recommended.
Calcium: Pregnancy and breastfeeding cause a temporary decrease in bone
mass which is usually regained after a woman stops breastfeeding. All adult
women should consume a daily minimum of 1000 mg of calcium; adolescents
should consume 1300 mg of calcium per day. If it is not possible to consume
enough milk or other foods that contain calcium, it is reasonable to take a
calcium supplement.
Vitamin D: Calcium absorption depends on having an adequate level of
vitamin D. Both breastfeeding and non-breastfeeding women require at least 5
micrograms per day of vitamin D when sunlight is inadequate; dependent on
the season and geographic position. Milk is the best source of dietary vitamin
D, with approximately 2.5 micrograms per cup.
Iron: Women who are not anemic after delivery and who breastfeed exclusively
do not usually have a menstrual period for the first four to six months. Thus,

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there is little iron lost in menstrual blood. An iron supplement is not usually
needed during this time. However, women who are anemic or lost a lot of blood
after delivery usually require an iron supplement.
Folacin: Folacin deficiency is common in pregnancy and thus many women
enter lactation with little reserves. Supplementation may thus be necessary.
Riboflavin: Riboflavin is used in milk production and thus a woman should
increase her intake by 0.5mgs.
Vitamin B6: This is especially important for women who are long term users of
oral contraceptives, since their sources are usually depleted.
Vitamin A:  An intake of 6000 IU is adequate for the average lactating woman.
However, a vitamin A supplementation of high-dosage (200,000IU) should be
given soon after delivery but no later than 8 weeks post-partum to protect
lactating women in vitamin A deficiency endemic areas.
Fluid intake: The average woman who exclusively breastfeeds produces about
750 to 800 ml of breast milk per day. It is adequate for a woman to drink when
she is thirsty and to watch for early signs that she is not getting enough fluids
- dark coloured urine, infrequent urination, dry mouth.
5.6 Breastfeeding
Breastfeeding is the act of feeding an infant / child with milk from the human
breast
5.6.1 Hormonal control of lactation
During pregnancy, estrogen from the ovary stimulates breast development.
Milk flow on the other hand is initiated after the infant begins to suckle the
breast. The vigorous suckling stimulates the anterior and posterior pituitary
glands. The anterior pituitary gland produces the hormone ‘prolactin’ which
stimulates milk production in response to emptying of the breast at a feeding.
The posterior pituitary glands releases the hormone ‘oxytocin’ which stimulate
the release of milk (let down reflex) from the breast in response to suckling by
the infant. It does this by causing contraction of smooth muscles that line the
alveoli and milk ducts. Emotions have an influence on oxytocin production

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such that sometimes when a mother hears her child crying, a let-down may
occur. Emotions or pain may also act in the contrary by inhibiting the let-down
reflex. Thus being relaxed is key to optimal breastfeeding.
Another hormone, ‘progesterone’, produced in the placenta also stimulates milk
production.
5.6.2 Milk composition (quality and quantity)
Human breast milk is generally adequately balanced in all the nutrients
required by a baby, up to the age of 6 months. After 6 months, the infant’s
needs outstrip the breast milk supply, necessitating complementary foods.
Looking at specific nutrients, maternal malnutrition must be very severe before
the total milk fat content is reduced. However, the fatty acid profile reflects
maternal dietary intake. In addition, the fat content varies within a feed. Hind
milk which is secreted at the end of a breastfeeding session contains
substantially more fat than foremilk which is secreted at the beginning of a
breastfeeding session. Energy, protein, fat and carbohydrate content is
relatively constant. Protein content tends to decline slightly with duration of
lactation but is not affected by maternal under nutrition.
Nutrients whose low maternal intake or stores reduce their content in breast
milk and consequently impacting on infant development include Vitamins A,
B1, B2, B6 and B12, and Iodine and selenium. Infant stores of most of these
nutrients are low and readily depleted, making the infant dependent on a
consistently adequate supply from breast-milk and/or complementary foods.
Their concentration in breast-milk can be rapidly restored by increasing
maternal intake. There is another group of nutrients that maternal intake and
stores have little effect on human milk concentrations and infant status.
Because milk concentrations are not reduced when the mother is deficient, she
is vulnerable to further depletion during lactation. They include Vitamin D,
folic acid, calcium, iron, copper and zinc. Supplementing the mother with these
nutrients during lactation is likely to benefit her more than the infant.

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5.6.3 Breastfeeding and lactation Suckling
Breastfeeding is required for the continued synthesis of prolactin and release of
oxytocin and it thus needed for the maintenance of milk production (lactation)
and let-down. Adequate milk output in turn boosts the mother’s confidence
and ability to breastfeed without milk shortages. Early supplementation of
breast milk with other foods (before 6 months of age) leads to less vigorous
suckling which in turn results in reduction in milk output. Therefore, the two
(breastfeeding and lactation) have an amplifying effect on each other. Have you
ever heard of women complaining of inadequate milk? If so, find out about
their infant feeding practices.
5.6.4 Contraceptives and lactation
The use of oral contraceptives both before conception and during lactation is
known to lead to lowered milk production.  In some cases, some nutrient stores
are reduced due to the drugs. An example is Vitamin B6
5.6.5 Importance of breastfeeding
a) Exclusive breast feeding helps to prevent pregnancy.
b) Breast feeding soon after delivery makes a mothers’ womb tighten and
reduces bleeding. it also helps her loose the pregnancy weight easily.
c) Breast feeding makes mothers and babies happy. It helps them develop a
close relationship which is important for the normal social and emotional
development of children.
d) It does not have to be bought (milk); it therefore reduces family
expenditure on infant food and also minimizes national expenditure on
imported infant foods.
e) It is always at the right temperature, so it does not burn the baby or
make him cold.
f) It is always clean and sterile, so no preparation is required before it is fed
to the baby.
g) It has everything the baby needs to grow strong and develop. The
nutrients by breast milk are enough to meet all the baby’s growth

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 requirements for up to 6months of life. If the baby is premature, the
mother produces special milk to meet his special needs.
h) It contains protective elements which guard the baby against infections.
If the baby is not given breast milk, he will frequently develop illness
particularly chest infections and diarrhea.
i) If the mother is breast feeding correctly, she produces more milk as the
baby grows and sucks more during the first 6months. She can produce
enough for twins. Her milk supply quickly returns to normal if the illness
or something else has made it become less. Milk does not just “go away”
or “dry up” unless there is a problem in the method of feeding.
j) Breast milk is freely available for the infant when he needs it. The can
feed on demand and just about anywhere.
5.6.6 Breastfeeding Complications
a) Breast Engorgement. It is when the breast tissues become full with milk,
blood and other fluids. This causes the breast to be very full, become
hard and painful and nipples to appear flattened and tight. It results
from a delay in breastfeeding
Management:
 Show mother how to breastfeed
 Use a warm towel/ cloth to massage and facilitate milk flow
 Proper breast attachment
b) Sore nipples
It results from poor latching on the breast by the infant. If attachment feels
uncomfortable, the mother should break the baby’s suction, take the baby off
the breast and re-latch them. A mother can express some milk at the end of a
feed, spread it on the nipples and leave it to air dry. The pain usually stops as
soon as the attachment improves and nipples heal quickly. If a mother is
positive, she should stop breastfeeding from the affected breast

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 c) Thrush
It may result in sore nipples. It may be caused by candida yeast infection and
may result to deep pink nipples that are tender and white patches and
increased redness in the mouth of the infant.
d) Tongue tie
May also be a cause of sore nipples. It is a tight frenulum beneath the tongue
and the baby cannot put his tongue forward enough to get beneath the teat of
the areola and nipple.
e) Blocked ducts
Is when a tender swelling forms in one part of the breast because milk is not
flowing from that side due to blockage in the duct.
Management:
 Mother to feed child on the side that is swollen
 When baby is breastfeeding, the mother to gently massage the swelling
towards the nipple
 Wash the breast with warm water
 Express milk while gently massaging the swollen part
 Mother to hold the baby in different positions while breastfeeding to
ensure milk is removed from all parts of the breast
f) Flat Nipples
Most often improve during breastfeeding. Management may include reassuring
the mother that she can breastfeed and showing her how to get enough breast
to the mouth. If necessary, she can express and feed he baby with cup for a few
days. She should continue offering the breast to the baby. Many babies learn to
attach in a few days.
g) Mastitis and breast abscess.
If engorgement or blocked duct persists, mastitis (inflammation) may develop.
Part of the breast becomes red, hard and very tender while other parts look
normal.
Management:

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  It is essential to remove the milk. If possible the baby should continue
feeding or the mother to express the milk
 Medication ( anti-inflammatory analgesics)
 If it doesn’t improve in 24 hours, give antibiotics
There is no need for the baby to stop breastfeeding because the breast has an
infection. The bacteria will not make the baby ill and the antibiotics the mother
is given is safe for the baby. However if the mother feels so much pain during
breastfeeding or has fear of the baby feeding from the infected breast, she may
express an discard the milk until the breast heals. She should stop feeding if
she is HIV positive.
h) Leaking
Many women experience milk leaking from their breasts during the early
weeks. Because the oxytocin reflex works on both breasts at the same time,
milk may drip from one side while the baby is feeding from the other.
Management:
 Show the mother how to stop the leaking by pressing her wrist or hand
against the nipple for a minute or two
 During a feed she can use a pad of cloth or tissue paper to absorb the
milk.
 The mother should avoid plastic-coated breast pads, which keep the
nipples moist and vulnerable to skin problems.
5.6.7What to avoid during lactation
5.6.7.1 Fish
Some fish have high levels of methyl mercury, a type of mercury. High levels of
mercury in the blood can be harmful to an infant or child's developing nervous
system. Avoid eating any shark, swordfish, king mackerel, or tilefish, as they
have high levels of mercury. Eat no more than two servings a week of fish and
shellfish that are lower in mercury e.g. shrimp, canned light tuna, salmon, and
catfish. Do not eat more than one serving per week of cooked fish that was
caught in a local pond, river, lake, or ocean.

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5.6.7.2Alcohol
 When a breastfeeding woman consumes alcohol, a small amount is passed
into her breast milk. For an average-weight woman, it takes about two hours
for one serving of alcohol to clear completely from her body.
5.6.7.3 Caffeine
 Most breastfeeding women can drink moderate amounts of caffeine without it
affecting their infant. However, some infants are sensitive to caffeine and
become irritable or have difficulty sleeping, even with small amounts of
caffeine. The sensitivity to caffeine usually lessens over time.
5.6.7.4 Tobacco
Infants of parents who smoke have an increased risk of a number of
conditions, including pneumonia, asthma, ear infections, bronchitis, and
sudden infant death syndrome (SIDS), among others. Reducing or stopping
smoking can decrease these risks. However, women who smoke are still
encouraged to breastfeed their children.

Students’ assignment
Learners to visit a health facility MCH section and give a health talk on
breastfeeding

5.6.7.5Illegal drugs: Such as marijuana, amphetamines, phencyclidine (PCP),

cocaine and heroin are not safe for both mother and baby. Women who use
these drugs should not breastfeed.

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UNIT 6: NUTRITION IN 0-6 MONTHS
Unit Objectives
At the end of this unit, the learner should:
1. Understand the developmental milestones in early infancy
2. Understand vulnerability in newborns
3. Explain feeding options
The World Health Organization and UNICEF recommend exclusive breast-
feeding for the first six months of life and the continuation of breast-feeding,
together with appropriate complementary feeding, up to two years of age or
beyond. Exclusive breastfeeding is giving an infant no other food or drink (not
even water), apart from breast milk (including expressed breast milk), except
for vitamins, mineral supplements or medicines in the form of syrups or drops.
6.1 Developmental milestones
4-6 weeks, the baby is attentive to familiar faces (mother). The infant can lift
his/her head from time to time when he is supported from his mother’s
shoulder or can turn his head a little from side to side while lying flat.
A baby will stare at a window, if there is a source of light. At this stage, the
baby already knows that it can get attention by crying for it.
At 8 weeks, the child can lift the chest for a short distance from a flat surface
especially when it has been laid on its abdomen. About this time the posterior
fontanelle closes.
It can kick his feet, he is attentive to speaking voices, his eyes can now focus
and it can follow a moving person. He may smile at familiar faces.
12-16 weeks, the infant can hold its head steadily while supported on the
mothers shoulder. He will turn his head freely while looking at people.
He will smile while looking at a familiar face and will show pleasure by making
a familiar sound, can start introducing weaning diet.
24 weeks (6 months), this time start getting full hand control and can sit with
only slight support. At this stage a child can roll from side to side especially
when put in bed.

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It starts recognizing sound especially that of the mother and grasping objects
and banging them. They reach on bright objects. At this stage the first tooth
erupts. It starts tasting objects by putting them in the mouth. At this stage the
birth weight should have been doubled
6.2 Vulnerable newborns
Low birth weight infants are those born weighing less than 2500 g and are
categorized as vulnerable. These are further subdivided into: •Very Low Birth
Weight (VLBW): Birth weight <1,500 g •Extremely Low Birth Weight (ELBW):
Birth weight <1,000 g

5.6.2.1 Complications of Preterm Babies

a) Temperature instability - inability to stay warm due to low body fat.
b) Respiratory problems:
 Chronic lung disease/bronchopulmonary dysplasia - long-term
respiratory problems caused by injury to the lung tissue.
 air leaking out of the normal lung spaces into other tissues
 incomplete lung development
 apnea (stopping breathing) - occurs in about half of babies born at or
before 30 weeks
c) Cardiovascular:
 Too low or too high blood pressure
 Low heart rate - often occurs with apnea
d) Blood and metabolic:
 Anemia - may require blood transfusion
 Jaundice - due to immaturity of liver and gastrointestinal function
 Too low or too high levels of minerals and other substances in the blood
such as calcium and glucose (sugar)
 Immature kidney function
e) Gastrointestinal:

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 Difficulty feeding - many are unable to coordinate suck and swallow
before 35 weeks gestation
 Poor digestion
 Necrotizing enterocolitis (nec) - a serious disease of the intestine common
in premature babies.

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 f) Neurologic:
 Intraventricular hemorrhage - bleeding in the brain.
 Softening of tissues of the brain around the ventricles (the spaces in the
brain containing cerebrospinal fluid).
 poor muscle tone
 seizures - may be due to bleeding in the brain
 Retinopathy of prematurity - abnormal growth of the blood vessels in a
baby's eye.
g) Infections - premature infants are more susceptible to infection and may
require antibiotics
h) Premature babies can have long-term health problems as well. Generally,
the more premature the baby, the more serious and long lasting are the
health problems.
6.3 Infant Feeding options
 Exclusive breastfeeding
 Wet nursing- Having another woman breastfeeding your baby
 Commercial infant formula
 Home modified animal milk
 Breast milk bank
 Expressing and heat treating of breast milk
6.3.1 Replacement Feeding
Replacement feeding is the process of feeding a child who is not breastfeeding
with a diet that provides all the nutrients the child needs until the child is fully
fed on family food.
Adequate replacement feeding is needed throughout the time the child is at
greatest risk of malnutrition: that is at least two years old. If an infant is not
getting breast milk, milk in some other form is needed for at least the first six
months. It is also useful if some kind of milk is part of the diet up to two years
of age or more. Replacement feeding must be acceptable, feasible, affordable,
sustainable and safe.

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In addition to a source of milk, the child’s mother will need water, soup and
utensil to prepare the replacement feeds and also extra time.

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Infants in the first six months can be fed on :
 Commercial infant formula designed to meet the nutritional needs of an
infant for the first six months of life.
 Home-prepared formula. For example, formula made from modified fresh
liquid milk.
In full strength full cream milk, the level of protein and some minerals is too
high, and it is difficult for an infant’s immature kidneys to excrete the extra
waste. These milks require some modification to make the proportions more
appropriate. A commercial formula has been modified so that the
proportions of different nutrients are appropriate for infants feeding, and
micronutrients have been.
6.3.1.1 The advantages of commercial infant formula:
Giving only formula carries no risk of transmitting HIV to the baby, most of
the nutrients a baby needs have already been added to the formula and other
responsible family members cab help feed the baby. If a mother falls ill, others
can feed the baby while she recovers.
6.3.1.2.Disadvantages
 Unlike breast milk, formula does not contain antibodies that protects a baby
from infection
 A formula-fed baby is more likely to get seriously sick from diarrhoea, chest
infections and malnutrition, especially if the formula is not prepared
correctly
 A mother should stop breastfeeding completely or the risk of transmitting
HIV will continue
 A mother needs fuel and clean water to prepare the formula, and soap to
wash the baby’s cup
 Formula takes time to prepare and must be made fresh for each feed
 Formula is expensive, and you must always have enough money on hand
 The baby will need to drink from a cup. Babies can learn how to do this
even when they are young, but it may take time to learn

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6.3.2 Cows’ milk
- Infants should not be given unmodified cow’s milk as a drink before the age
of 9 months. Cow’s milk differs greatly from human breast milk in terms of
the quality and quantity of nutrients and immunological factors. Whole
cow’s milk has greater amounts of protein and minerals (calcium, sodium,
phosphorus, chloride, magnesium and potassium) and less carbohydrate,
essential fatty acids (linoleic and α-linolenic acids) and long-chain
polyunsaturated fatty acids, iron, zinc, vitamin C and niacin. The quality of
cows milk protein differs from human milk and is potentially allergenic to
the human infant. Whole cow milk may cause low Vitamin C intake since
the vitamin is usually easily lost when a food is heated. Cows’ milk may also
predispose an infant to anaemia because it contains little iron and in
addition, its allergens may cause stomach bleeding. The high protein and
sodium intake may also impose a high renal load on the baby’s less
developed kidneys.
- Some parents give skimmed and semi-skimmed milk to infants. Since
skimmed milk has had most of the fat removed and semi-skimmed milk
about half of the fat removed, they do not provide enough energy for the
growing infant. Sweetened condensed milk is also not recommended
because of its high sugar content.
- Fruit juices, sugar-water and dilute cereal gruels or porridges are
sometimes given instead of milk feeds, but these are not recommended as
alternatives in the age bracket of 0-6 months because of their nutritional
incompleteness.
6.4Characteristics of good infant feeding options.
The UN guidelines and policies states that when replacement feeding is
acceptable, feasible, affordable, sustainable and safe (AFASS) avoidance of all
breastfeeding by HIV infected mothers is recommended otherwise exclusive
breastfeeding is recommended for the first months of life then discontinued
when replacement food is AFASS

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A good infant feeding option should be:
 Acceptable
 Feasible
 Affordable
 Sustainable
 Safe
When deciding an option of feeding, it is important to balance the risk of HIV
transmission if infant is breastfed with the risk of serious illness and death.
Some of the factors that may increase the risk of passing HIV virus through
breastfeeding are:
 Recent infection with HIV
 Advance HIV infection
 Breast condition e.g. cracked or bleeding nipples
 Longer duration of breastfeeding

UNIT 7: NUTRITION IN 6 -24 MONTHS

Unit Objectives
At the end of this unit, the learner should:
1. Define terms used in this unit
2. Understand the developmental milestones in 6-24 months
3. Explain the concept of complementary feeding
7.1 Meaning of terms
Complementary feeding is defined as the process starting when breastmilk
alone is no longer sufficient to meet the nutritional requirements of infants and
other foods and liquids are needed along with breastmilk.
Responsive feeding- it is the reciprocal relationship between an infant or child
and his/ her caregiver that is characterized by the child communicating
feelings of hunger and satiety through verbal or non-verbal cues followed by an
immediate response from the care giver

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7.2Developmental milestones
9-10 months, it should be sitting without support. Starts crawling should be
able to differentiate between strangers and familiar faces.
Some may attempt to start standing. They develop one or two tricks like waving
goodbye, clapping hands. Anterior fontanelle starts to close
10-12 Months, it will start standing without support and walk with some help.
They will hold a cup without dropping it. The weight should triple the birth
weight. It starts obeying simple commands or orders. Connect certain sounds
(pupu, susu)
12-24 Months The baby starts to run, can kick a ball, can scribble at will,
point to pictures when they are named, say a sentence with two to four words,
repeat words overhead in conversations, show growing independence and
follow simple instructions
7.3 Complementaryfeeding
It is well recognized that the period from birth to two years is a critical window
period for the promotion of optimal growth, health and behavioral development.
After 2 years, it is very difficult to reverse stunting that has occurred. Poor
breastfeeding and complementary feeding practices coupled with high rates of
infectious diseases are the principle proximate causes of malnutrition during
the first years of life.
The target range for complementary feeding is generally between 6 to 24
months of age. In practice, caregivers will not know the exact amounts of
complementary foods offered to infants should be based on the principle of
responsive feeding.
Responsive feeding applies the principle of psychosocial care which includes:
a) Feeding of infants directly and assisting older children when they feed
themselves, being sensitive to their hunger and satiety cues
b) Feeding children and infants slowly and patiently encouraging them to eat
without forcing them

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c) If children refuse many foods, the caregiver should experiment with different
food combinations, tastes, texture and method of encouragement
d) Minimize destruction during meals if the infant or child loses interest easily
e) Feeding time is a period of learning and love and hence the caregiver should
talk to child or infant when feeding and maintain eye to eye contact
f) To cater for micronutrients, it is important to include a variety of foods
When starting on weaning, at 6 months, introduce cereals mixed with milk
then pureed vegetables and foods one by one. It is important to avoid mixing of
foods so you can be able to identify the foods the child is allergic to.
At 6 to 8 months, introduce mashed cereals, vegetables and fruit juices and
soft porridge
At 8 to 10 months, transition to cereals, softly cooked vegetables, minced meat
and legumes
At 10 to 12 months, continue to introduce a mix of various foods and start
transition diets to family meals. It is not advisable to give canned foods. The
consistency of food as the infant gets older adapting to infants requirements
and abilities
A complementary food should be:
 Healthy complementary foods are:
 Rich in energy and nutrients
 Prepared from a variety of foods
 Clean and hygienic
 Soft and easy to eat
 Easy for family to obtain
 Easy to cook
For the complementary food to be clean and safe for consumption the following
has to be followed:
 Wash hands with soap and water and for the child also
 Boil water for the child to drink and use it to prepare commercially prepared
food

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 Clean plate or bowl of baby carefully and allow it to air dry
 Cook food thoroughly to kill microorganisms
 Add protein rich or sweet foods to the meal a short time before consumption
 Freshly prepare the food at least twice a day
 Don’t keep porridge or other foods overnight
The use of already prepared complementary convenience food is advantageous
because:
 It is usually clean and safe
 It is quick and easy to prepare and may not need cooking
 Some are fortified with essential micronutrients e.g. iron and zinc
 They have a higher nutrient density than plain porridge if prepared correctly
The disadvantages may be it is too expensive and the cereals may be processed
so can be prepared with cold water and if the water is contaminated, it may
make the child sick

7.4 Risk of early complementary feeding

- Introduction of other food decreases the intensity and frequency of
suckling and as a consequence breast milk production is interfered with.
- Introduction of cereals binds iron in milk which is low in concentration.
- Diarrhea because in developed countries population has despised diet
and live in unsanitary environment.
- Enter pathogenic, micro-organisms may enter the child’s track during
feeding.
- Other long term risks e.g. obesity, hypertension, arteriosclerosis & food
allergy may result if the child is weaned too early.

Students’ activity
Practical- Preparation of Complementary foods in the Food lab

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UNIT8: NUTRITION FOR PRE-SCHOOLERS (25- 59 MONTHS)
Unit Objectives
At the end of this unit, the learner should:
1. Define terms used in this unit
2. Understand the developmental milestones in pre-schoolers
3. Explain nutritional requirements for pre schoolers
4. Understand feeding habits of preschoolers
8.1 Meaning of terms
Food allergy- the adverse characteristics to food that involve an immune
response( food hypersensitivity characteristics)
Finger foods- foods that can be picked with fingers
Food neophobia- is refusal to eat new foods( picky or fussy eating)
Food jags- Refusing to eat all except one foods
8.2 Developmental milestones
 They become more independent  Help to dress and undress
 Are inquisitive themselves
 They notice the difference  Can sing a song
between boys and girls  Stands on one feet
 Recall part of a story
8.3 Nutritional requirements
8.3.1 Energy
As the preschool child grows, he becomes increasingly mobile, the energy
requirements also increases. Therefore if the child is given insufficient food, the
child will not only be underweight but also have hindered growth. The rate of
growth fluctuates from one age to another. Upto 10 years of age there is no
difference as far nutritive requirements are concerned. Insufficient calorie
intake can lead to protein deficiency.
8.3.2 Proteins
The increase in bone mass that must accompany bone growth requires positive
nitrogen balance that is met by protein intakes of 1.5 to 2 g/kg body weight.

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The increase in total body size needs a larger vascular system to transport
nutrients to the tissues and waste products away from the tissues. All these
activities create a need for proteins.
8.3.3 Fat
Fat energy including invisible fat for children should be 25% of total energy
and essential fatty acid energy is 5 – 6%.
8.3.4 Minerals
Calcium requirements of children are calculated on the basis of the amount of
calcium accretion in the body. This deposition is not uniform throughout
growing period, but would be relatively greater during early childhood and
during adolescence than during the other periods of growth. Deficiency of
calcium can affect the bones of growing children. Milk is the best source of
calcium. Hence the diet of preschool child should include 1 – 2 glasses of milk
per day.
The daily requirements of iron for growth will be 0.2 mg. To meet the increased
demand for iron, iron rich foods like rice flakes, egg yolk and greens should be
included in the diet. Dietary lack of iron accompanied by hookworm infection
can lead to anemia.
8.3.5 Vitamins
The incidence of vitamin A deficiency is high among Indian children whose
dietary intake is less than 100 mcg. According to the studies, children receiving
food supplements, which provide a total of 300 mcg of vitamin A per day, for
over a period of six months, do not get signs of vitamin A deficiency. Deficiency
of vitamin A in children can cause bitot’s spots, night blindness or in severe
cases total blindness. Milk, eggs, carrots and green leafy vegetables contain
vitamin A and should be included in diet.
8.3.6 Feeding a preschooler
 Provide regularly scheduled snacks and limit unplanned eating
 Poor behaviors should not be tolerated at meal times
 Offer a variety of foods

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 Don’t pressure child to eat or force them to finish their food as it may lead
to overeating
 Avoid distractions at meal times
 Give small portions for small children
 Limit processed foods and sugary drinks as it spoils their appetites
 Make the food as interesting and attractive as possible
 Teal and coffee should be avoided as they overstimulate the system
8.4 Feeding habits
 Vegetable and fruits- Fruits are usually well liked while vegetables are
usually less liked. Avoid strong vegetables or fruits and prefer crisp raw
vegetables and fruits cut into small pieces to eat as finger foods. Mixed
vegetables are usually less tolerated than individual ones.
 Proteins (Milk, cheese, eggs, meat and legumes) - Portions need to be
relatively small. Egg is usually preferred hard- boiled or scrambled. Meat
should be properly cooked, soft and easyto chew
 Temperature- Children prefer lukewarm and not hot food so some food
remains in their plates and become dry and gummy such that the child
refuses to eat it. Thus small portions should be served at a time
 Single foods- they usually prefer single foods to combination dishes. It is al
earning period hence they are able to recognize and name food on the basis
of shape, color, texture an d taste and this identifiable characteristics
should be retained as much as possible
 Food jags and food neophobia
8.5 Nutritionand health problems in pre-schoolers.
 Dental Problems- which may result from nutrient deficiency, fermentable
carbohydrate or susceptible teeth
 Anemia- It may result from poverty, parasitic infestation and parenteral
ignorance
 Obesity- It may result from inactivity, equating weight gain to good infant
car, watching while snacking and using food as a reward for good behavior

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 Parasitic infestation-  Constipation
 Food allergies  Protein Energy malnutrition

Students’ activity
Practical- Visit a pre-school and give a health talk to care givers

UNIT 9: NUTRITION FOR SCHOOL GOING CHILDREN

Unit Objectives
At the end of this unit, the learner should:
1.Define terms used in this unit
2. Understand the concept of nutrition in school going children
9.1 Meaning of terms
School going children- Are children between ages 6 to 12 years
Dental carries- Scientific word used to define tooth decay or cavities
9.2 Nutrition and Health problems for the school-going children
a) Obesity- Results from inactivity, overeating and snacking. Obesity is a
nutritional disorder and is a major risk factor for cardiovascular disease
in adulthood. Obesity is also implicated in the development of insulin
resistance limiting the body's ability to absorb glucose.
b) Dental Carries- Dental caries are caused by over indulging in sugary
foods such as soft drinks and confectionery may predispose school aged
children to poor dental health. The risk of tooth decay is greatest with
the consumption of large amounts of sticky sugary and starchy foods
that stick to the teeth (or example, sweets, sodas, lollies, and candies).
c) Food refusal- they dislike certain foods because of its color, texture or
are just picky
d) Allergies
e) Anaemia- Iron-deficiency anaemia may develop in children whose diet is
iron-deficient. Iron is an oxygen-carrying component of blood. Anaemia
in school-aged children may result in deleterious effects including lower

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 school achievement due to impaired cognitive development, poor
attention rate and general fatigue.
f) Undernutrition- It may result from undernutrition from a young age,
restriction of intake in poverty and consumption of low value snacks
The feeding habits for school going children are influenced by increased poverty
levels, peer influence, illness and disease.
9.3 Nutrition requirements for the school going.
Maintaining a balanced diet and regular exercise is important for all
individuals, especially school-aged children (6-12 years). These children are
required to eat a variety of foods from each food group to ensure optimal intake
of all vitamins and minerals. At the same time, they may face new challenges
regarding food choices and habits. Decisions about what to eat are partly
determined by what is provided in school, at home, the influences from friends
at school, and the media, especially television.
Poor nutrition compromises both the quality of life of school-aged children but
also their potential to benefit from education. Attaining optimal nutrition
involves eating atleastthree meals a day and two nutritious snacks, as well as
limiting the intake of high sugar and high fat foods. Consuming generous
amounts of fruits, vegetables, lean meats and low fat dairy products, including
three servings of milk, cheese or yoghurt to meet their calcium requirement,
can also prevent many medical problems. This includes becoming overweight,
developing weak bones, and developing diabetes.Adequate nutrition of school
aged children will also ensure they grow to their full potential, and provide the
stepping stones to a healthy life.The essential nutrients for optimal health
include:
 9.3.1 Energy
Carbohydrates and fats provide energy for growth and physical activity. During
periods of rapid growth, appetites increase and children tend to eat constantly.
When growth slows, appetites diminish and children eat less at meal times.
The brain needs energy to function properly and hence the supply of glucose is

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relevant and critical. Cognitively demanding tasks, such as schoolwork, require
regular supplies of glucose to the brain in order to enhance cognitive
functioning and improves memory and mood.
 9.3.2 Protein
Protein builds, maintains and repairs body tissue. It is especially important for
growth. It's important that parents encourage children to eat two to three
servings of protein daily. Good sources of protein for children include meat,
fish, poultry, milk and other dairy.
 

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9.3.3 Calcium
Calcium is important in building strong bones and teeth. Bone density suffers
when calcium needs are not met during childhood years. Osteoporosis, a
weakened bone disease affects a significant proportion of adults. This begins in
childhood if diets are not providing adequate calcium-rich foods. Milk and dairy
products and from some dark green, leafy vegetables are good sources of
calcium.
 9.3.4 Iron
Children need iron because of rapidly expanding blood volume during growth.
Meats, fish, poultry, and enriched breads and cereals are the best sources of
dietary iron.

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UNIT 10: NUTRITION IN ADOLESCENCE
UnitObjectives
By the end of this unit, the learner should be able to:
1. Define terms used in adolescents
2. Describe factors that contribute to vulnerability in adolescents
3. Explain nutritional requirements in adolescents
10.1Meaning of terms
Puberty/ Pubescence- Hormonal secretion and appearance of secondary
sexual characteristics and ends when sexual reproduction becomes possible (9-
13 female) (12-16 male)
Adolescence – This is the period between childhood and adulthood, where
rapid body growth and mental development takes place.
10.2 Body changes in adolescence
At this stage, the adolescence are vulnerable because they peak velocity of
increase in stature and weight proceeding menarche and spermatogenesis and
is a period of rapid physical growth and development. There is also sexual
maturity and terminating with cessation in growth and stature.
10.2.1 Boys
 Growth of hair in armpits
 Increase in height and weight
 Their voice break
 Experience wet dreams
 Attraction towards opposite sex
 Becomes sexually active
 Pimples appears on the face
 Shoulders become broader
10.2.2 Girls
 Hips broaden
 Breasts start to appear
 Pimples may appear on the face

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  Growth of hair in private parts
 Increase in size and weight
 Keeps attention towards them
 Attraction towards opposite sex -
 Becomes sexually active
10.3 Nutrition and Health problems in adolescence
a) Obesity- It may result from unusual food choices, snacking and lack of
variety in meals
b) Anorexia Nervosa- It is emaciation brought about by voluntary
starvation. It is attributed to an obsession in attaining a slim figure and
may result to amenorrhea, cardiac failure and electrolyte imbalance.
c) Bulimia Nervosa- It is consuming large quantities of food then inducing
vomiting.
d) Dieting/ Skipping meals
e) Binge eating- It is characterized by recurrent episodes of eating large
quantities of food( often very quickly and to the point of discomfort)
f) Snacking- Usually involves eating energy dense food that is low in other
nutrients
g) Anemia- Mostly common in adolescent girls due to the onset of menarche
and menstruation
10.4 Nutrition requirements during adolescence
The nutrient requirements of individual teenagers differ greatly, and food
intake can vary enormously from day to day, so that those with deficient or
excessive intakes on one day may well compensate on the next. In this period
of life, several nutrients are at greater deficiency risk including calories, iron,
zinc and calcium. Generally, nutrient requirements are greater for males than
females.
a) Iron
Adolescents are particularly susceptible to iron deficiency anemia because of
their increased blood volume and muscle mass as they grow and develop. This

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raises the need for iron for building up hemoglobin stores in blood and
myoglobin in muscle. The increase in lean body mass (LBM), composed mainly
of muscle, is more important in adolescent boys than in girls. In preadolescent
years, LBM is about the same for both sexes. Once adolescence starts,
however, the boys undergo a more rapid accumulation of LBM for each
additional kilogram of body weight gained. Menstruation in girls contributes to
elevated iron. Remember that iron from animal foods (haem iron) is much
better absorbed than iron from plant sources (non-haem iron). Vitamin C and
animal proteins assists in the absorption of non-haem iron. A deficiency of iron
causes anaemia, which leads to fatigue, confusion, and weakness. Adolescent
boys need 12 milligrams of iron each day, while girls need 15 milligrams.
b) Calcium and Vitamin D
About 45% of adult skeletal mass is formed during adolescence, although its
growth continues past the adolescent period. The achievement of peak bone
mass and density during childhood and adolescence plays an important role in
reducing the risk of osteoporosis later in life. Girls should be keener on these
nutrients as they are more at risk for osteoporosis than boys later in life. The
skeleton accounts for at least 99% of the body stores of calcium and the gain in
skeletal weight. Calcium for the growth of the skeleton must be derived from
the diet. By eating several servings of dairy products, green leafy vegetables,
calcium-fortified soy products, and other calcium-fortified foods and beverages,
the recommended calcium intake can be achieved. Remember that apart from
calcium, vitamin D and phosphorous are also needed for building of strong
bones. Physical activity, especially weight bearing exercises, is also essential
since they stimulate bone building and retention.
c) Calories
Adolescents need additional calories to provide energy for their rapid growth
and activity. Boys ages 11 to 18 need between 2,500 and 2,800 calories each
day. Adolescent girls need approximately 2,200 calories each day. This is a
significant increase from childhood requirements. To meet these calorie needs,

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teens should choose a variety of healthy foods, such as whole grains, lean
protein sources, low-fat dairy products, fruits, and vegetables.
Stress and emotional upsets can affect the energy balance in adolescents by
making them consume too little or too much food. Infections, nervousness,
menstrual, dental or skin problems (acne) can result in depression of appetite,
and those adolescents on marginal diets are the most vulnerable. We should
also remember that obesity is a potential risk. Simple sugars and saturated
fats intake should be controlled. Including food and nutrition in the school
curricula should enable children and adolescents to have the knowledge to
make informed choices about their nutrition.

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 d) Protein
Protein is important for growth and maintenance of tissues and muscle.
Adolescents need between 45 and 60 grams of protein each day. In adolescence
growth occurs in the breasts, hips, muscles, blood and most tissues.
Remember boys are more muscular as we saw in iron above. Protein is a
limiting factor for growth and should not replace carbohydrate as a main
source of energy. It should account for 12-14 % of the energy intake in
adolescence.
e) Thiamine, Riboflavin and Niacin:
 These nutrients play a major role in energy metabolism and thus with the
increased energy intake in adolescence, their intake should also be increased.
f) Folate and Vitamin B12
These are essential for DNA and RNA synthesis and are needed in higher
amounts when tissue synthesis is occurring rapidly. Rapid growth in
adolescence thus necessitates their increased need.
g) Zinc
Zinc is needed for growth and sexual maturation or puberty. Lack of adequate
zinc usually results in hypogonadism and growth retardation in both males
and females. Zinc is naturally present in various foods such as meat, poultry,
dairy products, beans, whole grains and nuts arerichin zinc.  
10.5 Increased Nutritional Needs
The physical changes of adolescence have a direct influence on a person's
nutritional needs. Teenagers need additional calories, protein, calcium, and
iron.
10.5.1 Calories- Adolescents need additional calories to provide energy for
growth and activity. Boys ages 11 to 18 need between 2,500 and 2,800 calories
each day. Adolescent girls need approximately 2,200 calories each day. This is
a significant increase from childhood requirements. To meet these calorie
needs, teens should choose a variety of healthful foods, such as lean protein
sources, low-fat dairy products, whole grains, fruits, and vegetables.

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10.5.2 Protein-It is important for growth and maintenance of muscle.
Adolescents need between 45 and 60 grams of protein each day. Most teens
easily meet this requirement with their intake of beef, pork, chicken, eggs, and
dairy products. Protein is also available from certain vegetable sources,
including tofu and other soy foods, beans, and nuts.
10.5.3 Calcium-Adequate calcium intake is essential for development of strong
and dense bones during the adolescent growth spurt. Inadequate calcium
intake during adolescence and young adulthood puts individuals at risk for
developing osteoporosis later in life. In order to get the required 1,200
milligrams of calcium, teens are encouraged to consume three to four servings
of calcium-rich foods each day. Good sources include milk, yogurt, cheese,
calcium-fortified juices, and calcium-fortified cereals.
10.5.4 Iron- As adolescents gain muscle mass, more iron is needed to help
their new muscle cells obtain oxygen for energy. A deficiency of iron causes
anemia, which leads to fatigue, confusion, and weakness. Adolescent boys need
12 milligrams of iron each day, while girls need 15 milligrams. Good sources of
iron include beef, chicken, pork, legumes (including beans and peanuts),
enriched or whole grains, and leafy green vegetables such as spinach, collards,
and kale.
10.6Factors influencing dietary intake of adolescents
 Physical image/ body image  Environment(Media, peer
 Independence pressure)
 Time pressure  Financial limits
 Knowledge of nutrition
10.7Nutritional concerns in adolescence
10.7.1 Eating Patterns
Adolescents have a tendency to eat differently than they did as children. They
tend to eat away from home, develop irregular eating habits and skip meals.
One of the most frequently missed meals is breakfast, yet breakfast plays an
important role in providing energy and nutrients after an overnight fast, and

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helps in concentration and performance at school. To meet their nutritional
requirements, adolescents should eat at least three meals a day, including
breakfast. Apart from skipping meals, they are exposed to periodic food fads
and slimming trends. In addition, because of after-school activities and active
social lives, sitting down for three meals a day is not easy and snacks could
easily replace meals. Most snacks are high in fat, salt and sugar and tend to
have little nutritional value thus exposing them to weight gain, diabetes and
cardiovascular diseases. Educating the teenager to choose snacks that are low
in fat, salt and added sugar is thus important.

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10.7.2 Eating Disorders
Adolescents are a group that is usually at risk for eating disorders since their
food choices are often influenced by social pressure to achieve cultural ideals of
thinness, gain peer acceptance, or assert independence from parental
authority. Fear of gaining weight may lead to overly restrictive diets, exercises,
and/or excessive eating as a way of coping with the physical and emotional
changes that come with this age. Some teens resort to self-induced vomiting or
laxative use to control their weight. Girls and women are more prone to eating
disorders than boys and men. These disorders predispose an individual to a
heart attack, stroke, anaemia, high blood pressure and high cholesterol, kidney
disease and/or failure, osteoarthritis and bone deterioration.
10.7.3 Overweight and Obesity in adolescents
Due to lack of physical activity and an increase in the amount of "junk food"
available to them, the prevalence of obesity and overweight among adolescents
is on the rise. There is a positive energy balance (more energy is consumed
than is spent). This has led to an increase in obesity-related diseases like
diabetes and heart disease. Overweight children and adolescents are more
likely to be overweight or obese as adults. Therefore, health professionals
should emphasize healthy eating and the importance of staying active to this
group.
10.7.4 Peer pressure
Teenagers are particularly vulnerable to peer-pressure, and can easily give in to
food and slimming trends in order to ‘fit in’ with their age mates. Skipping
meals, dieting and consumption of or avoidance of certain foods is likely. It is
thus important for parents to make healthy eating part of the socialization of
their children starting from childhood through adolescence.
10.7.5 Use of oral contraceptives
The use of oral contraceptives is common among girls to avoid pregnancies.
They usually have negative nutritional effects for instance; they reduce serum
folate levels which in turn reduce zinc levels. This then lowers immunity,

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sexual development and skeletal and muscle growth and development. Long
use of contraceptives also reduces pyridoxine levels in breast milk in the
future. On the flip side, they improve iron levels due to reduced menstrual flow,
increase serum copper levels, calcium absorption and conversion of carotene to
vitamin A.
10.7.6 Alcohol, tobacco and recreational drugs
Alcohol impacts negatively on food intake and affects the absorption of
nutrients like zinc and folacin. Hard drugs like cocaine are known to reduce
appetite leading to weight loss. Marijuana is said to increase hunger but its
users are known to weigh less than non-users. Smokeless tobacco is known to
increase blood pressure, blood sugar and chances of oral cancer. It also
reduces potassium levels in the body, and intake of fruits and vegetables.
Interventions should be developed to provide positive guidance so that
adolescents do not engage in intake of these substances.
10.7.7 Pregnancy in adolescence
When an adolescent becomes pregnant, she needs enough nutrients to support
both her baby and her own continued growth and physical development. If her
nutritional needs are not met, her baby may be born with low birth weight or
other health problems. There is also an increased risk for medical
complications and maternal mortality. For the best outcome, pregnant
teenagers need to seek pre-natal care and nutrition advice early in their
pregnancy. Parental guidance is required to avoid early pregnancies since they
have far more implications than just nutrition.
10.7.8 Athletics and sports
Adolescents involved in athletics and other sports may feel pressure to be at a
particular weightor perform at a certain level, and be tempted to adopt
unhealthy coping habits like crash dieting, taking performance boosting
supplements, or eating unhealthy foods to fulfil their hearty appetites. For
female athletes taking such measures, there is an increased risk for delayed

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menarche, irregular menses and loss of bone density. A balanced nutrient
intake is important for a good health status and performance.
10.8Nutrition education and counseling of the youth.
Educate and counsel on the following:
 Excessive Tv, video and computer use and lack of physical activity
 Overconsumption of sweetened beverages
 Excessive portion sizes
 High consumption of fast foods
 Skipping breakfast
 Lack of vegetables, fruit and fiber in the diet
UNIT 11: NUTRITION IN ADULTHOOD
Unit Objectives
By the end of this unit, the learner should be able to:
1. Define terms used in this unit
2. Explain nutritional requirements in adulthood
3. Explain factors influencing intake in adulthood
11.1 Meaning of terms
An adult- is a human being or living organism that is of relatively mature age
11.2Nutrient requirements for adults
Growth is no longer energy demanding in adulthood and BMR is relatively
constant among population groups of a given age or gender. Habitual physical
activity and bodyweight are the main determinants for the diversity in energy
requirements for adult populations with different lifestyles. The diversity in
body size, body composition and habitual physical activity among adult
populations with different geographical, cultural and economic background
does not allow a universal application of energy requirements based on total
energy expenditure in groups with specific lifestyles.
Dietary energy intake of a healthy well-nourished population should allow for
maintaining an adequate BMI (18.5- 24.9 kg/m²)
The recommended kilocalorie intake for adults with different activities

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Sedentary (Kcal/Kg) Moderate (Kcal/Kg) Active (Kcal/Kg)
Overweight 20-25 25- 30
30-35
Normal 25-30 30-35
35-40
Underweight 30-35 35-40
40-45
 Protein is required for almost every function in the human body. Adults
require protein to maintain lean muscle mass, healthy hair, skin and nails.
Active adults need more proteins than the minimum requirement. The
protein needs of healthy adults are 0.8- 1g of protein per kg of body weight
recommended.
 Healthy fats- Replace saturated and trans fats with unsaturated fats.
Saturated fats have a single bond therefore is saturated with hydrogen while
unsaturated fats have a double bong. Trans fats are partially hydrogenated
oils
 Vitamins and minerals- provide adequate amounts of fruits and vegetables
to avoid deficiencies

11.3 Factors influencing dietary intake in adults

 Level of knowledge regarding nutritional value of food
 Food preferences and family eating habits
 Individual cooking skills and availability of cooking equipment
 Cost of food
 Peer influence
 Socioeconomic status
 Food availability
 Emotions
 Environment: family and living situations

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UNIT 12:GERIATRIC NUTRITION
Unit Objectives
By the end of this unit, the learner should be able to
1. Define terms used in this unit
2. List the nutrition related problems in the elderly
3. Discuss the changes in old age/ late adulthood that influence nutrition
4. Explain the nutrient requirements of the elderly
12.1 Meaning of terms
Most developed world countries have accepted the chronological age of 65 years
as a definition of 'elderly' or older person, but like many westernized concepts,
this does not adapt well to the situation in Africa. While this definition is
somewhat arbitrary, it is many times associated with the age at which one can
begin to receive pension benefits. At the moment, there is no United Nations
standard numerical criterion, but the UN agreed cutoff is 60+ years to refer to
the older population.
The elderly are specifically vulnerable to malnutrition and providing them with
adequate nutrition encounters many practical problems including:
 Their nutritional requirements are not well defined. Since both lean body
mass and basal metabolic rate decline with age, an older or elderly person
energy requirement per kilogram of body weight is also reduced.
 The process of ageing also affects other nutrient needs e.g. while some
requirements for some nutrients may be reduced, requirements for others
may increase.
 Micronutrient deficiencies are common due to factors such as reduced food
intake and lack of variety in the foods consumed
 Decreased immune function which contributes to increased morbidity and
mortality
Geriatric is the study of health problems in the elderly while gerontology is
the science concerned with social, economic and medical problems of the
elderly

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12.2 Physiological changes in old age
The following are typical physiologic changes that occur in old age that can
affect nutritional status
a) Body composition changes as fat replaces muscle, in process called
sarcopenia. Research shows that exercise, particularly weight training,
slows down this process. Because of the decrease of lean body mass, basal
metabolic rate declines (about 5% per decade during adulthood). Total
caloric need drop, and lowered protein reserves slows the body’s ability to
respond to injury or surgery. Body water decreases along with the decline in
lean body mass
b) Gastrointestinal (GI) changes include a reduction in digestion and
absorption. Digestive hormones and enzymes decrease, the intestinal
mucosa deteriorates, and the gastric emptying time increase. As a result,
two conditions are more likely to occur: pernicious anemia and
constipation. Pernicious anaemia may result because of hypochlorhydria,
which decrease vitamin B12 absorption. Constipation, despite considerable
laxative use among older people, may result from slower GI motility,
inadequate fluid intake, or physical inactivity
c) Musculoskeletal changes occur. A progressive drop in bone mass starts
when people are in their 30s or 40s; this accelerates for women during
menopause, making the skeleton more vulnerable to fractures or
osteoporosis. Adequate intake of calcium and vitamin D helps to retain bone
intact
d) Geriatric nutrition must take into account sensory and oral changes.
Decrease in all the senses, particularly in the taste buds that affect
perception of salty and sweet tastes, nay affect appetite. Xerostomia, lack of
salivation, affects more than 70% of the elderly. Also, denture wearers chew
less efficiently than those with natural teeth do.

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e) Other organ changes may occur. Insulin secretion is decreased, which can
lead to carbohydrate intolerance, renal function deteriorates in the 40s for
some people.
f) Cardiovascular changes may occur. Reduced sodium intakes become
important as blood pressure increases in women over 80 (but, interestingly,
it declines in older men). Serum cholesterol levels peak for men at age 60
but continue to rise in women until age 70.
g) Immuno-competence decrease with age. The lower immune function means
less ability to fight infections and malignancies. Vitamin E, Zinc and some
other supplements may increase immune function
12.3Nutrient requirements for the elderly
Calories: Caloric needs reduce due to more body fat, less lean muscle and
reduced activity. The challenge for the elderly is to meet the same micro-
nutrient needs as when they were younger, yet consume fewer calories. They
should choose "nutrient-dense" foods in relation to their calories. For example,
low-fat milk is more nutrient dense than regular milk since its nutrient content
is the same, but it has fewer calories because it has less fat. About 60 percent
of calories should come from carbohydrates, with emphasis on complex
carbohydrates. Glucose tolerance may decrease with advancing years. Complex
carbohydrates put less stress on the circulating blood glucose than refined
carbohydrates.
Fats: Reducing the overall fat content in the diet is recommended because of
chronic diseases. Besides, it is the easiest way to reduce caloric intake.
Saturated fat (animal fats) should particularly be restricted. For people above
the age of 75, fat restrictions are less likely to be beneficial. In addition, fat
restriction is not appropriate for those who have suffered weight loss or have
little appetite. In fact for them, additional fat may be used to boost the caloric
intake.
Fibre: Many elderly people have problems of constipation and bowel problems
because of reduced gut motility and inactivity. Adequate fibre and plenty of

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fluids help maintain normal bowel function. Fibre also reduces the risk of
intestinal inflammation. Excessive amounts of very high-fibre foods are
however also nor recommended since they are too bulky and may interfere with
the absorption of some nutrients. Consumption of cereal foods, fruit and
vegetables should be encouraged to ensure adequate fibre.
Protein: Protein needs usually do not change as our years advance. Protein
absorption may decrease as we age, and our bodies may make less protein.
However, this does not imply that protein intake should be increased, because
kidney function declines and excess protein could stress the kidneys. Protein
deficiency on the other hand can lead to nutritional deficits. Protein is
important for the development and regeneration of body cells, especially the
muscles.
Vitamins and Minerals: Illness stresses the body and may use up whatever
stores there are, making the person vitamin deficient. Medications also
interfere with many vitamins and minerals. Eating nutrient-dense foods
becomes increasingly important when calorie needs decline but vitamin and
mineral needs remain high. Since the body can store fat-soluble vitamins, the
elderly are at lower risk of fat-soluble vitamin deficiencies.
Iron: Anaemia is a common problem in the elderly. Poor dietary intake,
absorption, use of some drugs and blood loss are often the causal factors.
Adequate iron can be sourced from red meat and non-meat sources daily.
Absorption is improved by consuming vitamin C-rich foods along with meals,
like fruit juice or fresh fruit or vegetables.
Zinc: Zinc is important for a healthy immune system and wound healing.
Many of the elderly suffer from pressure ulcers. It also improves taste acuity in
people where stores are low. Together with vitamins C and E, and the
phytochemicals lutein, zeaxanthin and beta-carotene, zinc may help prevent or
slow the onset of age-related macular degeneration. To obtain these nutrients,
one should consume at least five servings of fruits and vegetables, especially

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dark green, orange and yellow ones. Good choices include kale, spinach,
broccoli, peas and oranges.
Vitamin E: Studies show that eating foods rich in vitamin E, like whole grains,
nuts, vegetable oils and seeds, may help reduce the risk of Alzheimer's disease.
However, the same benefits are not enjoyed with vitamin E from supplements.
Calcium and Vitamin D: Adequate intakes of calcium help maintain bone
strength by slowing the rate of calcium loss from bones, which begins after the
age of 30 and accelerates in later years, especially in women. If bone density
decreases, osteoporosis (bone loss) develops over time. Bone degeneration is
not only due to calcium deficiency but also partly to genetics. The elderly need
about 1,000 mg of calcium a day. Vitamin D is required for calcium
metabolism and its deficiency in elderly people can lead to bone softening and
distortion. Adequate outdoor exercise is also helpful. Post-menopausal women
may need a calcium supplement if they can't get enough from the diet.
Vitamin B12: Low levels of the vitamin have been associated with age-related
hearing and memory loss. Normally, the body gets vitamin B12 by separating it
from protein in food during digestion, enabling it to be absorbed through the
intestines. But many of the elderly suffer from atrophic gastritis which causes
an increase in bacteria in the stomach and small intestine. These bacteria can
interfere with the body's ability to absorb vitamin B12. Many elderly people
therefore, need to take in extra vitamin B12.
Folate: Vitamin B9 is related to B12 metabolism in the body and is believed to
improve hearing. However, if B12 levels are not adequate, high folate levels may
be a health concern. As we age, the amount of folate needed to absorb vitamin
B12 decreases. The concentration of homocysteine in the blood rises as the
body's folate levels go down. High homocysteine levels are a risk factor for
heart attack, peripheral vascular disease and stroke.
Vitamin A: The carotenoid, leutein, found in dark green leafy vegetables like
spinach, is believed to decrease the risk of the chronic eye disease macular
degeneration.

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Water/ Fluids: Adequate water intake reduces stress on kidney function. As
we discussed earlier in this lecture, kidney function declines with age.
Adequate fluid intake also eases constipation. With the aging process, the
ability to detect thirst declines, and so the elderly should not wait to drink
water until they are thirsty but should make it a habit to drink plenty of fluids.
12.4 Factors influencing dietary intake in the elderly
 Financial status  Mental and psychological
 Appetite health
 Dental health  Disease
 Ability to swallow  Medications
 Eating alone  Reduced ability to taste and
smell
12.5 Intervention strategies for geriatrics.
 Prevention of chronic diseases  General care
 Feeding  Physical exercise
 Counseling on stress management
 Management and treatment of chronic diseases
12.6 Common elderly persons nutrition- related problem
Malnutrition
 While most elderly people maintain adequate, nutritional status,
institutionalized and hospitalized older adults are at high risk for
malnutrition than individuals who are living independently.
 Cancer and other chronic diseases, weakness, emaciated condition resulting
from cancer and other chronic diseases, accounts for about half of
malnutrition cases in elderly and institutionalized adults.
Dysphagia
 The incidence of dysphagia or difficult in swallowing, increases with age.
 Dysphagia results from condition such as stroke, Alzheimer’s or Parkinson’s
disease, multiple sclerosis, or physiological change such as loss of teeth or
poorly fitting dataries.

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 Inadequate dietary intake because of dysphagia can lead to weight loss,
dehydration and several nutritional deficiencies.
Fluids and electrolyte imbalance
Dehydration is the most common cause of fluid and electrolyte disturbances in
the older adults.
Reduced thirst sensation and fluid intake, medications such as diuretics and
laxatives and increase fluid need during illness contribute to dehydration in
elderly.
Adequate water intake guidelines are 1ml water / kcal energy consumed (for
example, 1.8 liters for a 1,800 calorie intake) or 25-30 ml/kg of weight for most
individuals.
In the elderly, there is total body water reduction.There is also diminished
water conservation by the kidney, while some medicines lead to fluid loss.
This is made worse by the fact that the elderly people take less fluids and their
sense of thirst is diminished.
The elderly also have trouble to get drinks and to get to the washroom in
addition to loss of bladder control, some of which lead to dehydration,
circulatory disorder, and kidney disorder, the intake of water should be 1ml/
kcal/ day.
Skin integrity
Skin breakdown is a common problem, particularly in bed ridden or
immunologically impaired people.
The most common skin breakdown is due to the pressure ulcer, which occurs
in 4% to 30% of hospitalized patterns and 2% to 23% of residents of skilled
care nursing homes.
Pressure ulcers are graded or staged to classify the degree of tissue damage.
Those with more serious stage II to stage IV ulcers have increased nutritional
needs.

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Protein needs increase to 1-1.5 protein /kg, calorie needs increase to 30-35
kcal/kg and 25-35 cc fluid /kg is recommended, reducing total dietary fat and
especially the amount of saturated fats is recommended.
Students’ assignment

Practical/ Assignment- Prepare meals for the elderly with different

complications

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REFERENCES

Bowman; B. and Rusell; R. (2001). Present knowledge in nutrition.Ilsi press

Washington D.C
FAO/WHO (2002). Human vitamin and mineral requirements. Report of a joint
expert consultation Bangkok; Thailand world health organization food and
agriculture organization of the United Nations Rome.
GOK; (2004) Policy guidelines on micronutrient deficiency control in Kenya.
National Micronutrient Deficiency Control Council (NMDCC) task force.
UNICEF and Egerton University.
International Dietetics & Nutrition Terminology (IDNT) Reference Manual:
Standardized Language for the Nutrition Care Process by American Dietetic
Association (Paperback - Sept. 2008)
Latham; m. (1997). Human nutrition in tropic Africa FAO; UNICEF; WHO;
publishing; Rome
SCN; (2005). Adolescence: A pivotal stage in the lifecycle. SCN news. Lavenham
press United Kingdom.
Whitney E.N; catalo C.B &Rolfes S.R.; (1998). Understanding normal and
clinical nutrition. 5th edition. International publishing company; Belmont.
World Health Organization, 2009. Infant and young child feeding: model
chapter for textbooks for medical students and allied health professionals.
World Health Organization, 2010. Indicators for assessing infant and young
child feeding practices: part 2: measurement.

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